Christian D. Helfrich

Purpose We successfully implemented the American College of Sports Medicine’s (ACSM’s) Exercise is Medicine® (EIM) initiative in a community oncology clinic. This study evaluated the impact of the evidence-based exercise intervention, adhering to ACSM guidelines on patient outcomes. Methods Using a quasi-experimental research design, An experienced ACSM-certified cancer exercise trainer delivered a 12-week biweekly, online group exercise intervention to 19 patients undergoing chemotherapy. Fifteen (78.8%) completed pre/post-self-report surveys on the program’s acceptability and impact, change in physical activity vital signs (PAVS), and health-related quality of life (HRQOL). We also assessed exercise uptake and PAVS at each clinic visit. Data were analyzed using t-tests and content analysis. Results On average, participants were 60 years, female (94%), non-Latino/White (60%), had stage IV cancer (92.3%), And had been receiving chemotherapy for An average of 10 months. The intervention was acceptable (86.4% enrollment) and had excellent retention (89.5%), with moderate adherence (68%). No adverse events were reported. Reasons for lack of adherence were medical reasons and treatment side effects. Compared to baseline, participants reported non-statistically significant increased aerobic exercise and improvements in HRQOL post-intervention. Participants rated the intervention as satisfactory, acceptable, and suitable (all > 4 out of 5 on a Likert scale). In open-text comments, six (40%) of the participants appreciated being asked about PAVS at the clinic, while three (20%) did not. Conclusions Patients undergoing chemotherapy, the majority of whom had stage IV cancer, could safely participate in an online group exercise program. Larger studies among different patient populations are needed.

Background: The Department of Veterans Affairs (VA), the largest nationally integrated health system in the United States, is transitioning from its homegrown electronic health record (EHR) to a new vendor-based EHR, Oracle Cerner. Experiences of the first VA site to transition have been widely discussed in the media, but in-depth accounts based on rigorous research are lacking. Objective: We sought to explore employee perspectives on the rationale for, and value of, transitioning from a VA-tailored EHR to a vendor-based product. Methods: As part of a larger mixed methods, multisite, formative evaluation of VA clinician and staff experiences with the EHR transition, we conducted semistructured interviews at the Mann-Grandstaff VA Medical Center before, during, and after going live in October 2020. In total, we completed 122 interviews with 26 participants across multiple departments. Results: Before the new vendor-based EHR went live, participants initially expressed cautious optimism about the transition. However, in subsequent interviews following the go-live, participants increasingly critiqued the vendor’s understanding of VA’s needs, values, and workflows, as well as what they perceived as an inadequate fit between the functionalities of the new vendor-based EHR system and VA’s characteristic approach to care. As much as a year after going live, participants reiterated these concerns while also expressing a desire for substantive changes to the transition process, with some questioning the value of continuing with the transition. Conclusions: VA’s transition from a homegrown EHR to a vendor-based EHR system has presented substantial challenges, both practical and cultural in nature. Consequently, it is a valuable case study for understanding the sociotechnical dimension of EHR-to-EHR transitions. These findings have implications for both VA leadership and the broader community of policy makers, vendors, informaticists, and others involved in large-scale health information technology implementations.

Purpose Despite proven benefits, few cancer patients exercise during chemotherapy. The American College of Sports Medicine’s Exercise is Medicine® (EIM) initiative describes a model to integrate exercise into oncology care, based upon assessing patients’ ability to exercise safely, advising on exercise benefits, and referring patients to exercise. We developed and tested a strategy to implement EIM in a community-based oncology clinic, to assess-advise-refer 20 patients undergoing chemotherapy to a 3-month online exercise class, and measured implementation outcomes. Methods Using a community-based provider participation in research (CBPPR) model, researchers and staff co-designed and tested a 4-level implementation strategy, with a goal of assessing-advising-referring 20 cancer patients to exercise. Surveys and interviews were conducted with 12 (100%) staff at baseline and post-implementation on acceptability/appropriateness/feasibility, perceptions of individual implementation roles, and organizational strengths/conditions. Data were analyzed using correlations, t-tests, and content analysis. Results The proposed strategy was revised in collaboration with staff who requested assistance for recruitment and data collection. EIM was successfully implemented with 41 (92%) patients assessed, 37 (90%) advised, and 22 (60%) referred to exercise classes. Barriers to implementation were staff shortages and time constraints; facilitators included research team supports. Staff’s perceived organizational strengths were positively correlated with exercise promotion acceptability, appropriateness, and feasibility. There were no statistically significant changes in implementation outcomes (acceptability/appropriateness/feasibility) post-implementation. Conclusions Using a collaborative model, EIM was successfully implemented in a community oncology clinic; however, the clinic required significant support from the research team. Adaptations to the EIM process may be required to improve implementation outcomes.

Objective. Assess factors contributing to variation in the use of new and evolving diagnostic and interventional procedures for percutaneous coronary intervention (PCI). Background. Evidence-based practices for PCI have the potential to improve outcomes but are variably adopted. Finding possible drivers of PCI procedure-use variability is key for efforts aimed at establishing more uniform practice. Methods. Veterans Affairs Clinical Assessment, Reporting, and Tracking Program data were used to estimate a proportion of variation attributable to hospital-, operator-, and patient-level factors across (a) radial arterial access, (b) intravascular imaging/optical coherence tomography, and (c) atherectomy for PCI. We used random-effects models with hospital, operator, and patient random effects. Overlap between levels generated cumulative variability estimates greater than 100. Results. A total of 445 operators performed 95,391 PCI procedures across 73 hospitals from 2011 to 2018. The rates of all procedures increased over this time. 24.45 of variability in the use of radial access was attributable to the hospital, 53.04 to the operator, and 57.83 to patient-level characteristics. 9.06 of the variability in intravascular imaging use was attributable to the hospital, 43.92 to the operator, and 21.20 to the patient. Lastly, 20.16 of the variability in use of atherectomy was attributed to the hospital, 34.63 to the operator, and 57.50 to the patient.Conclusions. The use of radial access, intracoronary imaging, and atherectomy is influenced by patient, operator, and hospital factors, but patient and operator-level effects predominate. Efforts to increase the use of evidence-based practices for PCI should consider interventions at these levels.

BACKGROUND The Department of Veterans Affairs (VA), the largest nationally integrated health system in the United States, is transitioning from its homegrown electronic health record (EHR) to a new vendor-based EHR, Oracle Cerner. Experiences of the first VA site to transition have been widely discussed in the media, but in-depth accounts based on rigorous research are lacking. OBJECTIVE We sought to explore employee perspectives on the rationale for, and value of, transitioning from a VA-tailored EHR to a vendor-based product. METHODS As part of a larger mixed methods, multisite, formative evaluation of VA clinician and staff experiences with the EHR transition, we conducted semistructured interviews at the Mann-Grandstaff VA Medical Center before, during, and after going live in October 2020. In total, we completed 122 interviews with 26 participants across multiple departments. RESULTS Before the new vendor-based EHR went live, participants initially expressed cautious optimism about the transition. However, in subsequent interviews following the go-live, participants increasingly critiqued the vendor’s understanding of VA’s needs, values, and workflows, as well as what they perceived as an inadequate fit between the functionalities of the new vendor-based EHR system and VA’s characteristic approach to care. As much as a year after going live, participants reiterated these concerns while also expressing a desire for substantive changes to the transition process, with some questioning the value of continuing with the transition. CONCLUSIONS VA’s transition from a homegrown EHR to a vendor-based EHR system has presented substantial challenges, both practical and cultural in nature. Consequently, it is a valuable case study for understanding the sociotechnical dimension of EHR-to-EHR transitions. These findings have implications for both VA leadership and the broader community of policy makers, vendors, informaticists, and others involved in large-scale health information technology implementations. CLINICALTRIAL

Background Patient enrollment levels at Veterans Health Administration (VHA) facilities change based on Veteran demand for care, potentially affecting demands on staff. Effects on burnout in the primary care workforce associated with increases or decreases in enrollment are unknown. Objective Estimate associations between patient enrollment and burnout. Design In this serial cross-sectional study, VHA patient enrollment and workforce data from 2014 to 2018 were linked to burnout estimates for 138 VHA facilities. The VHA’s annual All Employee Survey provided burnout estimates. Participants A total of 82,421 responses to the 2014–2018 All Employee Surveys by primary care providers (PCPs), including physicians, nurse practitioners, and physician assistants; nurses; clinical associates; and administrative clerks were included. Respondents identified as patient-aligned care team members. Main Measures Independent variables were (1) the ratio of enrollment to PCPs at VHA facilities and (2) the year-over-year change in enrollment per PCP. Burnout was measured as the annual proportion of staff at VHA facilities who reported emotional exhaustion and/or depersonalization. Each primary care role was analyzed independently. Key Results Overall enrollment decreased from 1553 enrollees per PCP in 2014 to 1442 enrollees per PCP in 2018 across VHA facilities. Forty-three facilities experienced increased enrollment (mean of 1524 enrollees/PCP in 2014 to 1668 in 2018) and 95 facilities experienced decreased enrollment (mean of 1566 enrollees/PCP in 2014 to 1339 in 2018). Burnout decreased for all primary care roles. PCP burnout was highest, decreasing from a facility-level mean of 51.7% in 2014 to 43.8% in 2018. Enrollment was not significantly associated with burnout for any role except nurses, for whom a 1% year-over-year increase in enrollment was associated with a 0.2 percentage point increase in burnout (95% CI: 0.1 to 0.3). Conclusions Studies assessing changes in organizational-level predictors are rare in burnout research. Patient enrollment predicted burnout only among nurses in primary care.

Objectives: Electronic health record (EHR) inbox notifications can be burdensome for primary care providers (PCPs), potentially contributing to burnout. We estimated the association between changes in the quantities of EHR inbox notifications and PCP burnout. Study Design: In this observational study, we tested the association between the percent change in daily inbox notification volumes and PCP burnout after an initiative to reduce low-value notifications at the Veterans Health Administration (VHA). Methods: The VHA initiative resulted in increases and decreases in notification volumes for PCPs. For each facility, the proportion of PCPs reporting burnout was estimated using VHA All Employee Survey responses before and after the initiative in 2016 and 2018, respectively. Survey responses were aggregated for 6459 PCPs (physicians, nurse practitioners, and physician assistants) at 138 VHA facilities. Fixed effects regression models estimated the association of small and large increases and small and large decreases in notifications on burnout. Results: Daily inbox notifications per PCP decreased by a mean (SD) of 5.9% (30.1%) across study facilities, from a mean (SD) of 128 (52) notifications to 114 (44) notifications after the initiative. Fifty-one percent of facilities experienced reductions in notifications, 30% experienced no change, and 20% experienced increased notifications. PCP burnout was not significantly associated with any level of increase or decrease in notifications. Conclusions: Changes in notification volumes alone did not predict PCP burnout. Future research to reduce burnout might still address EHR notification volumes, but as part of a broader set of strategies that consider the other stressors that PCPs experience.