Evaluation and Treatment of Mild Traumatic Brain Injury Through the Implementation of Clinical Video Telehealth: Provider Perspectives From the Veterans Health Administration

Accepted Manuscript Evaluation and treatment of mild traumatic brain injury through the implementation of clinical video telehealth: Provider perspectives from the Veterans Health Administration Rachael N. Martinez, PhD, Timothy P. Hogan, PhD, Keshonna Lones, MHA, Salva Balbale, MS, Joel Scholten, MD, Douglas Bidelspach, MPT, Nan Musson, MA, CCCSLP, Bridget Smith, PhD PII:

S1934-1482(16)30256-8

DOI:

10.1016/j.pmrj.2016.07.002

Reference:

PMRJ 1743

To appear in:

PM&R

Received Date: 4 January 2016 Revised Date:

28 June 2016

Accepted Date: 9 July 2016

Please cite this article as: Martinez RN, Hogan TP, Lones K, Balbale S, Scholten J, Bidelspach D, Musson N, Smith B, Evaluation and treatment of mild traumatic brain injury through the implementation of clinical video telehealth: Provider perspectives from the Veterans Health Administration, PM&R (2016), doi: 10.1016/j.pmrj.2016.07.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Evaluation and treatment of mild traumatic brain injury through the implementation of clinical video telehealth: Provider perspectives from the Veterans Health Administration

Timothy P. Hogan, PhD2,3 Keshonna Lones, MHA1

Joel Scholten, MD5

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Salva Balbale, MS1,4

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Rachael N. Martinez, PhD1

Douglas Bidelspach, MPT5

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Nan Musson, MA, CCC-SLP6 Bridget Smith, PhD1,7

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Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines VA Hospital, Hines, IL;

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Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers

Memorial Veterans Hospital, Bedford, MA; 3

Division of Health Informatics and Implementation Science, Department of Quantitative Health

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Sciences, University of Massachusetts Medical School, Worcester, MA; Center for Healthcare Studies, Institute of Public Health and Medicine, Northwestern University

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Feinberg School of Medicine, Chicago, IL; Physical Medicine and Rehabilitation, Rehabilitation and Prosthetics Service, VA Central Office, Washington, DC 6

VHA Rehabilitation and Prosthetic Services, Gainesville VAMC, Gainesville, FL;

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Feinberg School of Medicine, Northwestern University, Chicago, IL;

Conflicts of Interest and Source of Funding: For all authors, no conflicts of interest were declared. This study was supported by the Department of Veterans Affairs, Office of Research and Development,

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Health Services Research and Development Service Quality Enhancement Research Initiative as grant RRP 11-418. The views expressed in this article are those of the authors and do not necessarily reflect

Address correspondence to: Rachael N. Martinez, PhD

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the position or policy of the Department of Veterans Affairs or the United States government.

Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital

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5000 South 5th Ave (151H) Bldg 1 D304 Hines, IL 60141-5151

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E-mail: [email protected]

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Phone: 708-202-7130; Fax: 708-202-2316

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Evaluation and treatment of mild traumatic brain injury through the implementation of clinical

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video telehealth: Provider perspectives from the Veterans Health Administration

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ABSTRACT

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Background: Substantial numbers of U.S. military Veterans who served in recent conflicts experience

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mild traumatic brain injury. Data suggests that as many as 25% of Veterans do not have a

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comprehensive traumatic brain injury evaluation to determine a diagnosis and develop a plan to treat

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symptoms. Technologies like clinical video telehealth offer a potential means to overcome travel

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distance and other barriers that can impact Veteran receipt of a comprehensive traumatic brain injury

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evaluation after a positive screening; however, little is known about implementing clinical video

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telehealth in this context.

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Objective: To examine the perspectives of Veterans Health Administration healthcare providers on

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implementing clinical video telehealth technology for the assessment and treatment of mild traumatic

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brain injury among Veterans of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation

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New Dawn.

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Design: Qualitative; semi-structured interviews

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Setting: Veterans Health Administration Polytrauma System of Care

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Participants: Twenty-six providers who participated in a Veterans Health Administration Rehabilitation

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and Prosthetic Services Teleconsultation Pilot Project for administering comprehensive traumatic brain

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injury over clinical video telehealth.

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Methods: Semi-structured interviews employing content-analytic techniques to assess provider

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experiences implementing clinical video telehealth for Veterans with traumatic brain injury, including

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inhibiting factors and best practices to administer comprehensive traumatic brain injury evaluations.

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Results: The most commonly reported inhibiting factors to implementing clinical video telehealth for

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traumatic brain injury evaluation and treatment included scheduling, setting up the clinic, and

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conducting physical exams over a virtual modality. To enhance clinical video telehealth implementation,

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participants described best practices including establishing solid communication and relationships with

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staff, building rapport with patients, and recognizing the unique needs of patients with traumatic brain

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injury.

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Conclusions: Implementing clinical video telehealth programs involves coordinating multiple steps with

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providers at different sites, highlighting the need for effective communication. Provider-patient

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communication also emerged as vital to successful clinical video telehealth implementation. These

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findings suggest that providers would benefit from efforts to build communication competencies.

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Keywords: traumatic brain injury; evaluation and treatment; clinical video telehealth; Veterans;

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implementation

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It is estimated that 15-20% of Veterans returning from Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND), have experienced at least one

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traumatic brain injury (TBI).1-4 Mild TBI can result in affective, somatic, and cognitive symptoms such as

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headaches; problems with sleep, balance, and/or memory; irritability; and sensitivity to light.5 To identify

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Veterans who may benefit from services, the Veterans Health Administration (VHA) implemented a

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national clinical reminder (CR) in April 2007 to screen for mild TBI.6-7 Veterans with positive results on

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the mild TBI CR are referred to a TBI Specialist for a Comprehensive TBI Evaluation (CTBIE).8 Recent

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studies suggest that many OEF/OIF/OND Veterans who are screened for TBI have co-morbid

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diagnoses such as depression, post-traumatic stress disorder (PTSD), pain, or insomnia,9-12 which

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suggests a need to ensure access to CTBIEs for thorough assessments and development of

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appropriate treatment plans. However, Veterans also face numerous challenges that may make it

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difficult for those with possible TBI to be evaluated in-person at a VHA facility. Previous studies suggest

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that PTSD-related problems with anger, trust, and social situations, as well as mild TBI-related

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problems with memory and attention, negatively impact appointment attendance, as can other factors

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including distance to facilities, frequent appointments, competing daily demands, and financial

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constraints.11

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VHA is a leader in the development and use of virtual care modalities to improve Veteran

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access to care. Clinical Video Telehealth (CVT) is a virtual care modality in which Veterans present at a

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VHA clinic that is convenient for them and connect with practitioners at distant facilities through

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interactive video which allows both parties to see and hear one another. For Veterans with possible

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TBI, the VHA Rehabilitation and Prosthetic Services initiated a CTBIE Teleconsultation Pilot Project

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with the goals of standardizing a CTBIE protocol for CVT, increasing the overall percentage of CTBIE

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completion, and improving access to care.

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Previous studies have demonstrated the effectiveness of telehealth applications to provide a

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variety of services to persons with TBI,13-17 and patients have generally reported satisfaction with

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treatments received through this modality.15,18 This evidence does not, however, address the potential 4

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issues associated with implementing CVT to provide care to persons with TBI. The introduction of a

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virtual modality like CVT has implications for both patients and providers, yet data regarding factors that

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influence integration of the technology into clinical practice are limited. We undertook the current study

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to examine how CVT is being implemented across VHA facilities for the evaluation and treatment of

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Veterans with possible TBI, including inhibiting factors and best practices employed to support uptake

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and use.

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METHODS

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We conducted a qualitative, formative evaluation study using semi-structured telephone interviews with a sample of VHA providers comprised of TBI Specialists and telehealth clinical

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technicians (TCT) who were part of the VHA Rehabilitation and Prosthetic Services CTBIE

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Teleconsultation Pilot Project. Interviews were conducted between April 2013 and September 2013.

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This study was approved by the Hines VA Hospital Institutional Review Board.

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Participants

We recruited participants from a list of 22 TBI Specialists and 18 TCTs involved in the CTBIE

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Teleconsultation Pilot Project, all of whom were invited to complete a semi-structured interview and

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background questionnaire.

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Measures

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We designed a semi-structured interview guide consisting of open-ended questions and specific probes to facilitate dialogue with providers. The guide was reviewed by clinicians from VHA

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Rehabilitation and Prosthetic Services, refined, and then piloted in a test interview with a provider prior

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to data collection. Interview topics included (1) describing the step-by-step protocol for administering

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CTBIEs; (2) advantages and disadvantages of conducting CTBIE through CVT; (3) inhibiting and

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facilitating factors to implementing CVT for TBI assessment and management; (4) best practices for

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enhancing CVT implementation; and (5) concluding perceptions. Sample interview questions are listed

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in Table 1.

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Procedure

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We emailed providers to inform them of the opportunity to participate and then sent a follow-up email one week later with a formal invitation. Prior to the start of the interviews, participants were asked

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to complete a background questionnaire to document their professional background and experience.

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Two authors (R.M., S.B.) experienced in qualitative methods conducted the interviews over a 6-month

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period. Each interview lasted approximately 30 minutes, was audio-recorded, and transcribed verbatim.

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Verbal informed consent was obtained at the beginning of the interview.

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Data Analysis

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Interview transcripts were loaded into NVivo (Version 8.0) for coding and analysis. Analysis of the interview data proceeded through thematic content analysis, including the constant comparative

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method, which involves deriving basic concepts from data and comparing them with other data to

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facilitate meaningful categorization.19,20 The first author (R.M.) led the qualitative analyses for this

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project, and has both academic training and prior research experience leading qualitative analyses for

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other projects. Members of the research team have collaborated extensively on similar analyses. We

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initiated the coding process with a list of basic categories based on the topics addressed in the

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interview guide. These included facility characteristics, challenges to implementing CVT, and best

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practices to enhance CVT implementation. Within these categories, emergent subcodes were

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identified, and were defined in a codebook. To ensure rigor in this process, three of the authors (R.M.,

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S.B., K.L.) began by reviewing a subset of the transcripts independently and then met as a group to

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compare emergent subcodes. Two of the authors (R.M. K.L.) then coded the entire dataset using the

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categories and subcodes identified, refining codes as necessary. The initial list of basic codes and

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subcodes expanded quickly at the beginning of this process but became saturated after coding 10-12

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transcripts. The two authors met weekly to compare findings and resolve coding discrepancies.

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Descriptive statistics were used to analyze the background questionnaire data and to characterize the

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sample.

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RESULTS

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Sample

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As shown in Table 2, 26 providers (65% participation rate) participated in the study. Specifically, we recruited 22 TBI specialists of which 11 participated (50% participate rate) and we recruited 18

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TCTs of which 14 participated (77.8% participation rate). The overall sample was comprised primarily of

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TCTs (53.8%) and TBI Specialists (42.3%) who had a range of experience working with patients with

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TBI. Table 3 demonstrates providers’ experience working with patients with TBI by their role during the

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telehealth encounter. A majority of TBI Specialists (89%) reported more than three years of experience

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and most TCTs (67%) reported less than three years of experience caring for patients with TBI. As

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shown in Table 4, TBI Specialists were comprised of physiatrists, neurologists, and nurse practitioners.

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TCTs were comprised of individuals from various backgrounds (e.g., telehealth technology, nursing,

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etc.). For the CTBIE Teleconsultation Pilot Project, leadership recommended that TCTs review the TBI

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online training (approximately 1.5 hours), and participate in a face-to-face visit with the TBI Specialist

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during a consultation as well as a practice telehealth session with the TBI Specialist. A majority of the

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respondents (70%) indicated that they spend less than 50% of their time providing direct care (Table 2).

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The rest of their time is spent doing various other activities (e.g., administrative work, research,

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education) or caring for populations other than TBI.

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Process of Administering the CTBIE through CVT

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Participants described a multi-step process for administering the CTBIE through CVT,

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encompassing appointment preparation, the CVT appointment itself, and subsequent follow-up. From

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start to finish, the appointment lasts between 60 to 90 minutes. The TCT first provides the patient with

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screening tools to be completed in the waiting area, including the Neurobehavioral Symptom Inventory

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(NSI), Post-Traumatic Stress Disorder Checklist (PCL), and the Beck Depression Inventory (BDI).

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While the patient is completing the screening tools, the TCT readies the room for the appointment,

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setting up the CVT equipment and checking the peripherals. Before connecting through the CVT

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equipment, the TCT obtains verbal consent from the patient to proceed with the appointment and then

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elicits main complaints and vitals.

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During the CVT appointment, the TCT assists the TBI Specialist with the evaluation by

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administering the Montreal Cognitive Assessment (MOCA), Olfactory Testing (brief smell inventory),

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and Tandem Romberg test (balance test) while the TBI Specialist observes patient performance. In

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addition, the TCT and TBI Specialist review the patient’s responses to the NSI, PCL, and BDI. If

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needed, the TCT helps the TBI Specialist gather additional muscular (e.g., for focal weaknesses),

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sensory (e.g., pain), and reflex measures. After the evaluation, the TBI Specialist discusses findings

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and recommendations with the patient. Following the appointment, the patient fills out a patient

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satisfaction form, and the TBI specialist and TCT complete a progress note and conclude the encounter

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using diagnostic/procedure codes.21

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We asked providers about their perceptions of the advantages and disadvantages of

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administering the CTBIE through CVT. A majority of the providers expressed that a tremendous

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advantage is the travel convenience that it offers the Veteran. Providers also reported that many

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Veterans feel more comfortable at their local facility because the site and staff are familiar to them. In

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addition, providers reported that implementing CVT has allowed them to reach Veterans who had

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previously gone without assessment and treatment because of the distance barrier. Once providers

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have connected with Veterans over CVT for the CTBIE assessment, many report that this modality is

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sufficient for adequately assessing the Veteran for TBI. However, a small portion of providers report

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that one disadvantage to using CVT is their ability to evaluate comorbid conditions besides TBI,

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particularly pain issues and PTSD. In these instances, providers may prefer to see the patient face-to-

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face.

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Inhibiting Factors and Best Practices for Implementing CVT

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In the following sections, we summarize the inhibiting factors (Table 5) and best practices

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(Table 6) to enhance implementation. Within these categories, results are organized by steps in CVT

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implementation. Representative participant quotations are included to illustrate key findings. Quotations

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are labeled (MD = physician, NP = nurse practitioner, TCT = telehealth clinical technician, and Other)

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Inhibiting factors

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Setting up the CVT clinic

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Many providers reported challenges setting up the clinic prior to receiving patients. Establishing a suitable environment for conducting CVT appointments was often difficult, and included problems with

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insufficient space and lighting. The most common issue was conducting CVT appointments in small

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exam rooms. Providers reported that small exam rooms make it more challenging for the CVT camera

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to capture the entire exam, especially examining the patient’s gait to check balance and coordination.

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I don’t think that a small exam room is ideal for this. You need a larger room, or to be able to

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walk out into the hallway too with the camera to follow. We can’t do that from our room. [NP, 14]

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Another important consideration when evaluating Veterans with potential TBI is the lighting in the exam

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room/office. The lighting on the patient’s end should be bright enough that the providers on the other

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end of the CVT appointment can see the patient, but dim enough as to not bother the patient who may

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be experiencing sensitivity to light as a symptom of TBI and/or related conditions. Another challenge

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pertained to instituting proper CVT clinic stop-codes, which are identifiers utilized to identify workload

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for all outpatient encounters, inpatient appointments in outpatient clinics and inpatient billable

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professional services. Despite the availability of universal CVT clinical stop-codes from the

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aforementioned CTBIE Teleconsultation Pilot Project, the process of setting up stop-codes varied

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across sites and often entailed working with different staff which in turn required more time and effort to

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coordinate.

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Scheduling CVT appointments

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Other challenges emerged during the scheduling of CVT appointments. Existing practices

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required staff to schedule the patient at two clinics—the provider and CVT clinics. Coordinating

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appointments was difficult, not only because of hectic provider schedules, but because of limited

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availability at CVT clinics, and the possible double-booking of CVT equipment. Additionally, patients

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must be available at the same time as the provider, clinic slot, and equipment.

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Patient no-shows for scheduled appointments also introduced unique problems in comparison to face-to-face visits. Providers explained that scheduling around patients who arrive late or do not

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attend at all disrupts schedules at two clinics because it “blocks out both the provider as well as our

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telepresenter’s time” [Other, 10].

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Providers also expressed difficulty identifying appropriate patients for CVT. A few providers highlighted the importance of screening a patient’s record prior to offering CVT appointments to

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evaluate whether the patient would benefit more from a CVT or face-to-face encounter.

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It’s not always transparent when you’re evaluating or reviewing a person’s record as to whether

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telehealth would be the best way to go… Sometimes when you review someone’s case it seems

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pretty clear that perhaps this person would not be best served through telehealth just maybe

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due to the amount of distress they have expressed when they’ve talked to us or other providers,

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such things. But right now, we don’t have a formal process to decide yes or no for that. It’s more

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of a gut-level feeling. [MD, 1]

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Conducting CTBIEs over CVT

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Providers described a variety of inhibiting factors that they encountered when conducting evaluations and providing treatment over CVT. Many mentioned technical issues, including occasional

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delays in sound or trouble connecting over CVT given limited bandwidth and signal strength, problems

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hearing patients or the remote teams, and power outages. Providers acknowledged that most of these

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technical issues have been resolved over time by gaining more experience with the CVT equipment.

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Limited time and staffing were also reported as additional barriers. Some providers noted that

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CVT appointments require more preparation than typical face-to-face appointments given the need to

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check equipment and read a patient’s chart in advance (as opposed to speaking and reviewing the

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patient’s record simultaneously). Several providers mentioned that they would benefit from additional

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time or staff support to offset the increased workload.

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Another primary concern was the perceived limitation of evaluating physical symptoms over

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CVT. Without being physically present, many providers found it challenging to assess patients’ physical

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complaints through CVT. For certain parts of the physical exam, I think it’s a challenge too. The TCTs are great for basic

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musculoskeletal examinations, but when we get into more detailed exams, it’s a little bit harder

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not to be there and do the evaluations yourself. [MD, 19]

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Providers noted that patients with possible TBI often have comorbid issues such as pain and PTSD,

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and that these issues are more difficult to evaluate over CVT.

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There are some [patients] that clearly, if they were in the room, I think I could still see them

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better; I could get a certain feeling better about their level of anxiety, even their level of pain,

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and watch them and have a closer view of them than you can on CVT. […] For the ones that

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may have a TBI but the symptoms have resolved and they’re doing well and there are other

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things going on. Those are ok. But the ones that are really complicated, the ones that have a lot

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of issues still going on and trying to decide whether that’s coming from the TBI they had or it’s

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totally separate or it’s a mixture of both and they’re irritable and antsy. Those, I still think it would

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be nice if they were in the room. [NP, 3]

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Because the TBI Specialist must rely on the TCT or nurse to “be their hands” during the CTBIE to

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evaluate the patient’s physical symptoms (e.g., neuromuscular), it is beneficial for the Specialist to

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“have a high index of trust in the person who is doing the physical exam” [NP, 4]. Several providers

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highlighted the challenge of working with TCTs who have limited experience.

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Finally, some providers conveyed concern over coordinating care for patients across the

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provider and CVT clinics. In particular, providers were uncertain whether other sites followed their

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recommendations for treatment, or offered follow-up and subsequent education for patients. Their

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sense of uncertainty stemmed largely from their trust in other sites to follow through appropriately.

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What I want to make sure is that when we hang up, there’s follow-up education, if there’s

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discussion before and after the assessment or if the primary care provider has questions for the 11

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TCT. […] I just want to make sure that the Veteran doesn’t leave with conflicting information.

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[MD, 12]

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Best practices

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Providers discussed numerous practices and workarounds to address such obstacles and

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enhance CVT implementation at their sites.

Establishing solid communication and relationships with staff. Given the various interrelated, moving parts involved in implementing CVT services, many providers stressed the importance of

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working cooperatively with reliable and qualified staff. Providers explained that effective communication

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is essential to successfully implementing CVT. From coordinating appointment times to conducting the

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CTBIE, open communication between staff can circumvent problems such as double-booking

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appointments and inadequately assessing patient physical complaints.

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Most participants focused on the importance of establishing good communication between the TBI Specialist and TCT. Because TBI Specialists must rely on TCTs to “be their hands” during the

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appointment, providers stated that having a TCT on the patient’s end that not only understands the

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CVT technology but is also willing to learn, responsive to requests, and knowledgeable about relevant

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medical issues is essential to a successful appointment. These qualities may bolster trust and rapport

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between TCT and TBI Specialist, which in turn, can further facilitate a quality CVT experience. As one

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provider explained, “If you want this program to really work, then you need to make sure that the TCT

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and the physician are on the same page” [TCT, 23]. In many cases, the TCT traveled to the TBI

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Specialist’s site and received in-person training from the TBI Specialist on how to conduct a CTBIE and

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what is expected of them during the evaluation.

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[The physician] brought me up there for like two days to work with her and that helped a lot. Just

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to see how she runs the appointment from start to finish, basically I was going to do the same

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thing here but without her. [TCT, 8]

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Several TCTs and TBI Specialists felt this face-to-face time at the distant site was critical not only for

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establishing communication, but for moving the entire CVT program forward. From a TCT’s

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perspective: I traveled to [physician’s] site in order to receive orientation on what we wanted to do. […] So I

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think that if you want to have a solid program, you would need to train your TCTs and be trained

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by the physician that will be conducting the CVT clinics with them. […] Remember that if you

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want to have a successful CVT program or clinic, you need your provider to have full trust in

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your TCT. If you don’t have a trust relationship between the TCT and the provider, then they are

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not going to be satisfied with the results of the interview. [TCT, 17]

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From a TBI Specialist’s perspective:

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Getting to know your TCT, that’s your right hand. So getting to know your TCT on the same

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thing, them getting to know you and your style – I think it’s crucial; it makes the interview run

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smoothly. [MD, 19]

By interacting in-person prior to conducting CVT appointments, providers reported feeling more at ease

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with their counterparts at distant sites. Additionally, providers felt that continued interaction with their

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counterparts across CVT helped strengthen communication over time. Establishing rapport with patients. Another important tactic for enhancing evaluation and

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treatment for TBI over CVT is establishing rapport with patients. In many cases, this may entail

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personalizing the CVT visit for each patient. Several providers mentioned efforts to “normalize the CVT

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experience for the patient” [TCT, 22] and to treat the CVT appointment “like an office visit, like they’re

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actually here” [NP, 13]. Some providers mentioned setting up the camera to have a “shoulder-up, nice

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clear view” of both the TBI Specialist and patient in order to make the visit seem more personable [NP,

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13]. One provider shared his/her approach of keeping the mood light to make patients comfortable.

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Try to make it friendly and easy to speak to them. […] to give that feeling of “Hey yeah, this is

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cool, we do it all the time, you’re fine, come on in.” Make them comfortable, I’m friendly, I have a

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good sense of humor […] And [the TBI Specialist] always introduces himself and it’s very cute 13

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when he’s done he says, “Well sir, I’ll shake your hand over this screen” and always pretends

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like he’s shaking hands and he’s very aware of looking at the patient. [NP, 13]

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Providers reported that patients sometimes feel anxious when asked to come in for a CTBIE,

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regardless of whether the appointment is in-person or over CVT. To alleviate anxiety, a few providers

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reported explaining to the patient what the CTBIE will entail.

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It’s allaying the fear. When somebody gets a letter from the TBI clinic, they get worried, and so I

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try to just say, it’s not about your time in the military, it could be before the military or after. If you

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had a head injury, we want to know if you’re having any problems because we do have some

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services that might be most helpful for you and I explain too that we’re not going to do any

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wacky testing… [NP, 4]

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Patients’ unfamiliarity with CVT and/or technology, in general, has the potential to further increase

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anxiety about the appointment, and providers reported using different tactics to put patients at ease.

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One provider described a method for breaking the ice with patients which involved discussing topics

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unrelated to the actual evaluation while the TCT takes the vitals.

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You have to do an ice-breaker thing in the beginning, especially if you don’t know the patient

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because it might get a little personal. While my TCT is sort of doing the vital signs and getting all

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the information, I introduce myself and I start talking about nothing that has to do with the

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evaluations sort of to break the ice. [MD, 19]

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Recognizing the unique needs of patients with TBI. Beyond evaluating patients for TBI,

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providers recognized the need to assess patients for other possible issues, including comorbid

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concerns such as PTSD and pain. Providers described instances in which patients became very

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emotional while reliving the experience of their TBI and also emphasized the importance of connecting

313

some patients with mental health services in a timely manner.

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One of our primary roles, other than diagnosing accurately TBI or not, is trying to effectively

315

triage them into the system that already exists and how can we help jumpstart their pathway into

316

the system even if we don’t have to follow them up ever again, or case management. Mental 14

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health is their primary concern, hey, let me go put in that consult because he may not see

318

primary care for a couple of weeks. [MD, 12]

319

Utilizing accessible resources. Providers also mentioned that the support and resources that they received from leadership at their facility or the Telehealth Program Office facilitated CVT

321

implementation. One provider reported that the resources available on the VA telehealth intranet site

322

“helped a lot in terms of the setting up and the developing and continuing with the clinics” [MD, 19].

323

Another provider stated, “I think the program office has done a good job organizing [the CTBIE

324

Teleconsultation Pilot] and making resources available and the training, I mean, they’re very

325

accessible” [MD, 12]. Additionally, some providers found that developing their own training materials

326

was helpful in enhancing the effectiveness of their site’s CVT program. Specifically, one provider

327

described how a CVT coordinator created an organized binder for providers to reference which

328

included CVT dial-up numbers, equipment repair help, equipment cleaning information, and standard

329

operating procedures for TBI polytrauma teams.

330

DISCUSSION

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As evidenced by our data, implementing CVT programs involves considerable effort and multiple steps with providers at different sites, all of which places a premium on coordination.

333

Challenges to coordination that providers reported ranged from scheduling CVT appointments,

334

including coordinating schedules between two sites, to dealing with patient no-shows and identifying

335

appropriate patients for CVT. Ensuring effective communication between the sites was emphasized by

336

many providers as the single most important factor to ensuring the availability of all parties and

337

equipment at the time of an appointment.

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Identifying appropriate patients for CVT was an additional challenge. Overwhelmingly, providers

339

reported that patients have expressed satisfaction with care received over CVT; however, concerns

340

over patient appropriateness in our data suggest that CVT is not a one-size-fits-all virtual modality. The

341

complexities presented by patients with comorbid issues is a case in point, and further underscores that

342

the needs of some patients may be more readily addressed over CVT than others. Providers and 15

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patients may benefit from a screening tool and corresponding guidelines to systematically evaluate

344

whether a CVT or face-to-face appointment would be appropriate for a given patient. Effective communication between CVT team members, particularly between TBI Specialists and

346

TCTs, was another crucial element in implementation. Our data speak to the importance of one-on-one

347

training with the TBI Specialist to enhance TCT knowledge and skills. A recent study of a telebehavioral

348

health training for a deployed army reserve unit developed several best training practices, including:

349

“(1) maintain the hands-on component; (2) use lessons learned to develop scenarios; (3) incorporate

350

training into daily activities; (4) tailor training while ensuring that all stakeholders have the same base

351

knowledge set” (pp. 1326-7).22 These practices are relevant to many of the challenges identified in this

352

study. Hiring and training TCTs who have both technical and medical assessment skills can potentially

353

facilitate CVT appointments through enhanced trust between TCT and providers. Opportunities for

354

TCTs and providers to meet in-person prior to conducting CVT appointments may be a critical

355

ingredient in trust- and rapport-building efforts. As other studies have shown, the integration of virtual

356

care modalities into the care of complex patient populations is facilitated when clinical team members

357

have shared beliefs and assumptions regarding the nature of clinical activities, and collaborations

358

among team members are established or recognized as important to develop.23,24

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Effective implementation of CVT also hinges on the establishment of a solid relationship with

EP

359

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345

patients. Providers discussed the challenge of making a personal connection with patients via CVT and

361

found that properly positioning the camera is helpful for facilitating the patient-provider connection.

362

Research has shown that video monitor placement is vital for a successful telehealth encounter.25-27

363

More importantly, providers can actively make CVT visits more personal by normalizing the experience

364

and recognizing the unique needs of patients with TBI.

365

Limitations and Future Research

366

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There are limitations to this study. First, this was a descriptive study of a pilot project within a

367

single healthcare system. A strength, however, is that the pilot project included multiple medical

368

facilities from the largest integrated healthcare system in the United States. Comparative studies 16

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examining other telemedicine programs may identify other inhibiting factors and best practices to

370

implementing CVT that are not represented in the current analysis. Second, our findings are based on

371

self-reports of provider experiences and perceptions of CVT implementation for TBI evaluation and

372

management. Our sample of providers came from sites that had volunteered to be part of the pilot

373

project hosted by VHA Rehabilitation and Prosthetic Services, therefore suggesting that more

374

motivated individuals may have participated in our study. Generalizing these impressions to all VHA

375

TBI providers may not be appropriate. Finally, this study could have been strengthened by including

376

Veteran perspectives.

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Larger studies that include a variety of stakeholders (e.g., patients, leadership) could provide

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369

further insights into the multiple facets of implementing CVT for Veterans with specific conditions.

379

Efforts are needed to develop interventions that improve implementation of telehealth to provide

380

CTBIEs, and ultimately, improve access to care, patient satisfaction and follow-up care coordination,

381

and ensure that Veterans are receiving treatment to resolve their symptoms.

382

Implications for Application

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As implemented in the CTBIE Teleconsultation Pilot Project, CVT has considerable potential to improve access to TBI evaluation for a population that is dealing with numerous symptoms while

385

simultaneously managing various life responsibilities (i.e., work, family, etc.). Moreover, increasing

386

Veteran access to CTBIEs via CVT can also improve access to other much-needed healthcare services

387

(e.g., mental health). Most providers in our sample explained that a tremendous advantage of

388

administering CTBIEs through CVT is the convenience offered to Veterans, and that the technology has

389

allowed them to reach Veterans who had previously gone without assessment and treatment because

390

of geographic and distance-related barriers. Although no-shows provide greater challenges in wasted

391

time for providers and TCTs as well as underutilized space compared to in-person appointments, some

392

providers in our sample reported a reduction in no-shows for CVT appointments. Previous studies have

393

examined healthcare utilization and costs among Veterans with TBI; our results suggest that CVT

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supports more efficient use of services.28-31 However, no study has evaluated the cost-benefit of

395

implementing telehealth for evaluation and management of TBI, and this warrants research. A prominent challenge to using CVT for TBI evaluation and management was learning how to

397

use the CVT technology and addressing technical issues. In addition, providers expressed difficulties

398

working across sites to establish telehealth service agreements and schedule CVT appointments.

399

These infrastructural issues are currently being addressed in VHA as part of a national Telehealth

400

Scheduling System (TSS) that will embed electronic Telehealth Service Agreements. VHA’s efforts to

401

improve CVT implementation can be a model for other healthcare systems contemplating adoption and

402

use of the technology. Another pressing consideration is the availability of staff. Hiring more staff is not

403

always feasible, and clinical teams may benefit from clearly and meaningfully redefining roles to evenly

404

distribute responsibilities associated with CVT implementation.

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Our findings are corroborated by recent literature revealing factors and strategies for enhancing CVT use.26 Optimal utilization of CVT requires a basic technological infrastructure, site-to-site

407

technological compatibility, and sufficient technical support.26 Strategies that promote the successful

408

implementation of telemedicine programs include developing organizational protocols; offering training

409

to ensure that CVT users feel comfortable, competent, and ready to use the equipment32; and

410

supporting teamwork and collaboration across providers.26

411

Conclusion

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This study is the first to examine VHA provider perspectives regarding CVT implementation for

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the evaluation and treatment of Veterans with possible TBI. Provider-provider and provider-patient

414

communication emerged in our findings as vital to successful CVT implementation. As such, providers

415

are likely to benefit from efforts to further enhance communication competencies. Training of TBI

416

telehealth providers could possibly be enhanced by implementing live, interactive training sessions;

417

employing real scenarios during training; providing ongoing training; and tailoring training based on

418

roles. By integrating insights from past research and the current study into practice, CVT can be used

419

to improve access and quality of care for both Veterans with possible TBI, and other conditions. 18

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returning veterans. Santa Monica, CA: Rand Corporation: http://veterans.rand.org; 2008.

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3. Taylor BC, Hagel EM, Carlson KF, et al. Prevalence and costs of co-occurring traumatic brain

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injury with and without psychiatric disturbance and pain among Afghanistan and Iraq War

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Veteran VA users. Med Care. 2012;50:342-346.

4. Wilk JE, Thomas JL, McGurk DM, Riviere LA, Castro CA, Hoge CW. Mild traumatic brain injury

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(concussion) during combat: lack of association of blast mechanism with persistent

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postconcussive symptoms. J Head Trauma Rehab. 2010;25(1):9-14.

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5. Vanderploeg RD, Curtiss G, Luis CA, Salazar AM. Long-term morbidities following self-reported mild traumatic brain injury. J Clin Exp Neuropsyc. 2007;29(6):585-598. 6. Schwab KA, Ivins B, Cramer G, et al. Screening for traumatic brain injury in troops returning

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from deployment in Afghanistan and Iraq: Initial investigation of the usefulness of a short

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screening tool for traumatic brain injury. J Head Trauma Rehal. 2007;22:377-389. 7. VHA Directive 2007-013. Screening and evaluation of possible traumatic brain injury in

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Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans. [Internet]

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Washington, DC: Department of Veterans Affairs, Veterans Health Administration; 2007.

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8. VHA Directive 2010-012. Screening and evaluation of possible traumatic brain injury in

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Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans. [Internet].

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Washington, DC: Department of Veterans Affairs, Veterans Health Administration; 2010.

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Available online at : http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2176.

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9. Carlson KF, Nelson D, Orazem RJ, Nugent S, Cifu DX, Sayer NA. Psychiatric diagnoses among

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Iraq and Afghanistan War Veterans screened for deployment-related traumatic brain injury.

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Journal Trauma Stress. 2010;23(1):17-24. 10. Evans CT, St. Andre JR, Pape TLB, et al. An evaluation of the Veterans Affairs traumatic brain

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injury screening process among Operation Enduring Freedom and/or Operation Iraqi Freedom

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Veterans. American Acad Phys Med & Rehab. 2013;5:210-220.

11. Sayer NA, Rettmann NA, Carlson KF, et al. Veterans with history of mild traumatic brain injury

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and posttraumatic stress disorder: challenges from provider perspective. J Rehabil Res Dev.

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2009;46(6):703-713.

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12. Scholten JD, Sayer NA, Vanderploeg RD, Bidelspach DE, Cifu DX. Analysis of US Veterans

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Health Administration comprehensive evaluations for traumatic brain injury in Operation

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Enduring Freedom and Operation Iraqi Freedom Veterans. Brain Inj. 2012;26(10):1177-1184.

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13. Bell KR, Hoffman JM, Temkin NR et al. The effect of telephone counselling on reducing posttraumatic symptoms after mild traumatic brain injury: a randomised trial. J Neurol Neurosurg

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Psychiatry. 2008;79(11):1275-1281.

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14. Bourgeois MS, Lenius K, Turkstra L, Camp C. The effects of cognitive teletherapy on reported everyday memory behaviours of persons with chronic traumatic brain injury. Brain Injury.

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2007;21(12):1245-1257.

15. Brennan DM, Georgeadis AC, Baron CR, Barker LM. The effect of videoconference-based

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telerehabilitation on story retelling performance by brain-injured subjects and its implications for

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remote speech-language therapy. Telemed J E-Health. 2004;10(2):147-154.

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16. Huijgen BC, Vollenbroek-Hutten MM, Zampolini M, et al. Feasibility of a home-based

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telerehabilitation system compared to usual care: arm/hand function in patients with stroke,

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traumatic brain injury and multiple sclerosis. J Telemed Telecare. 2008;14(5):249-256.

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17. Topolovec-Vranic J, Cullen N, Michalak A, et al. Evaluation of an online cognitive behavioural

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therapy program by patients with traumatic brain injury and depression. Brain Injury.

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2010;24(5):762-772. 18. Bergquist TF, Thompson K, Gehl C, Munoz PJ. Satisfaction ratings after receiving internet-

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based cognitive rehabilitation in persons with memory impairments after severe acquired brain

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injury. Telemed J E-Health. 2010;16(4):417-423.

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developing grounded theory. 2nd ed. Thousand Oaks, CA: Sage Publications; 1998.

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19. Strauss A., Corbin JM. Basics of qualitative research: Techniques and procedures for

20. Lindlof R. Qualitative Communication Research Methods. Thousand Oaks, CA: Sage Publications; 1995.

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21. Comprehensive TBI Evaluation User Guide. Office of Rehabilitation Services. [VA Intranet site

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only]. Washington, DC: Department of Veterans Affairs, Veterans Health Administration; 2011.

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Available online at: http://vaww.rehab.va.gov/PMR/Comprehensive_TBI_Evaluation.asp,

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Accessed April 25, 2011.

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22. Mishkind MC, Boyd A, Kramer GM, Ayers T, Miller PA. Evaluating the benefits of a live, simulation-based telebehavioral health training for a deploying army reserve unit. Mil Med.

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2013;178:1322-7.

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23. Kairy D, Lehous P, Vincent C. Exploring routine use of telemedicine through a case study in rehabilitation. Rev Panama Salud Publica. 2014;35(5/6):337-44.

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24. Moehr JR, Schaffsma J, Anglin C, Pantazi SV, Grimm NA, Anglin S. Success factors for telehealth—a case study. Int J Med Inform. 2006;75(10-11):755-63. 25. Onor ML, Misan S. The clinical interview and the doctor-patient relationship in telemedicine. Telemed J E-Health. 2005;11:102-5. 26. Jarvis-Selinger S, Chan E, Payne R, Plahman K, Ho K. Clinical telehealth across the disciplines: lessons learned. Telemed & e-Health. 2008;720-5.

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28. Shore P, Goranson A, Ward MF, Lu MW. Meeting Veterans where they’re @: a VA home-based telemental health (HBTMH) pilot program. Int J Psychiat Med. 2014;48(1):5-17.

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delivered via telemedicine. Eur Eat Disord Rev. 2003;11:222-230.

29. Gagnon MP, Duplantie J, Fortin JP, Landry R. Implementing telehealth to support medical practice in rural/remote regions: what are the conditions for success? Implement Sci. 2006;1:18. 30. Stroupe KT, Smith BM, Hogan TP, et al. Healthcare utilization and costs of Veterans screened

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27. Mitchell JE, Myers T, Swan-Kremeier L, Wonderlich S. Psychotherapy for bulimia nervosa

and assessed for traumatic brain injury. J Rehabil Res Dev. 2013;50(8):1047-1068. 31. Rogers TJ, Smith BM, Weaver FM, Ganesh S, Saban KL, Stroupe KT, Martinez RN, Evans CT,

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Pape TLB. Healthcare utilization following mild traumatic brain injury in female Veterans. Brain

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Injury. 2014;28(11):1406-1412.

32. Moehr JR, Anglin CR, Schaffsma JP, Pantazi SV, Anglin S, Grimm NA. Video conferencing

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based telehealth: its implications for health promotion and health care. Methods Inf Med.

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2005;44:334-341.

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Table 1. Interview guide topic areas and sample questions Topic Area I: Contextual Issues – Team, Role, and Work Characteristics Tell me about the polytrauma care team that you are a part of at your facility.

RI PT

What is your role/contribution on the polytrauma care team? Topic Area II: Process of Administering the CTBIE through CVT

Tell me about the standard protocol for administering the CTBIE through CVT. Probes:

SC

Who and what is involved in prescreening activities? What is it like to communicate with the provider and/or Veteran at the distant facility? What happens after the encounter is

Topic Area III: Inhibiting Factors

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over?

Based on your experience, what problems or roadblocks do you see with protocol? Probes: Are there other things that have interfered with the administration of the CTBIEs through CVT? What are those things?

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Topic Area IV: Best Practices

Based on your experience, are there things that you think would make the protocol easier to implement/follow? Probe: What might those supports be?

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What do you do to resolve or alleviate these obstacles? Probe: Do you have any “workarounds” or “best practices” for these specific challenges?

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Topical Area V: Concluding Perceptions Reflecting back on our discussion, in your opinion, is there value in using CVT technology to administer CTBIEs? Based on your experience to date, what could VA be doing to try to support and improve use of CVT technology to administer CTBIEs?

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Table 2. Provider demographic characteristics Characteristics

N

Gender

26

Male

9

Age*

21 4

36-45 years

8

46-55 years

5

56-65 years

4

Role during TBI telehealth encounters TCT TBI Specialist

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Other

Total years worked with patients with TBI* Less than 3 years

EP

Greater than 10 years

% of time caring for patients with TBI**

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34.6

19.0

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25-35 years

65.4

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17

SC

Female

3-10 years

Percentage

38.1 23.8

19.0

26

14

53.8

11

42.3

1

3.8

21 9

42.9

6

28.6

6

28.6

20

< 50% of time caring for patients with TBI

14

70.0

> 50% of time caring for patients with TBI

6

30.0

*Data missing for 5 providers **Data missing for 6 providers

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Table 3. Crosstab of experience working with patients with TBI by provider role during telehealth encounters (n=21) Role in telehealth encounters TBI Specialist (n)

Less than 3 years

1

3-10 years

3

Greater than 10 years

5

8

3

1

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*Data missing for 5 providers

TCT (n)

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Total years worked with TBI patients*

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Table 4. Crosstab of provider specialty by provider role during telehealth encounters (n=25)

TCT (n)

Physiatrist

7

0

Neurologist

1

0

Nurse practitioner

3

1

Resident nurse

0

2

Nurse assistant

0

Physician assistant

0

Telehealth technician

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0

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Provider speciality

RI PT

TBI Specialist (n)

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Role in telehealth encounters

3

1

7

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Table 5. Inhibiting factors that complicate, impede, or disrupt the implementation of CVT for Veterans with TBI Inhibiting factors

N

Percentage

Space and lighting

10

Stop codes

2

35 8

SC

Scheduling CVT appointments

RI PT

Setting up the CVT clinic

Coordinating appointment time

46

6

23

M AN U

No-shows

12

Identifying appropriate patients for CVT

2

8

12

46

8

31

7

27

TCTs with limited medical knowledge/training

6

12

Making personal connection via CVT

5

19

Staffing

4

15

4

15

Conducting CTBIEs over CVT Technical issues Physical exam limitations

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Time issues

AC C

Coordinating care

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Table 6. Best practices for enhancing effective implementation of CVT for Veterans with TBI N

Percentage

Establishing solid communication and relationships with staff

15

50

Establishing rapport with patients

11

42

RI PT

Best Practices

Recognizing the unique needs of patients with TBI

7

26

5

19

5

19

Placing reminder phone calls and sending letters to decrease no-shows

5

19

Offering flexible scheduling

5

19

Having patients complete paperwork at appointment

3

12

Completing necessary prep work to facilitate communication

2

8

Utilizing accessible resources

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Adapting to various scenarios (in the moment) (flexibility)