Stephanie Leah Shimada

Introduction: Lung cancer is among the top three most frequently diagnosed cancers, and the leading cause of cancer-related death among United States veterans. Improved screening and treatment for lung cancer has led to an increasing number of survivors, but many still face a persistent decline in physical function and overall quality of life. Exercise can improve outcomes, but most structured and supervised programs are delivered in hospital-based settings. Veterans often face substantial barriers to participation in these programs, including comorbid chronic illness, geographic isolation, and transportation challenges. Therefore, this study will examine the feasibility and acceptability of delivering a telehealth-supported home-based exercise intervention to improve physical activity and quality of life for veterans who are lung cancer survivors. Methods: A protocol for a single-arm, nonrandomized, prospective feasibility pilot. Up to 15 veterans diagnosed with lung cancer will be recruited from the Veterans Affairs (VA) Boston Healthcare System for a three-month intervention. Participants will choose a single low-intensity telehealth exercise from the VA’s MOVE! ^® Coach App and wear an activity tracker (Fitbit). Semi-structured qualitative interviews will be conducted at three points in the study. Participants will have the option to simultaneously participate in VA’s Whole Health coaching and will be asked to share their data via VA’s Share My Health Data App. Primary outcomes will measure feasibility, acceptability, and perceived appropriateness of the intervention. Secondary exploratory outcomes will examine changes in physical activity and health-related quality of life; while improvements are anticipated, this study is not powered to detect statistically significant differences. Descriptive statistics will be calculated. Qualitative interviews will be audio recorded and analyzed using directed content analysis methods. Ethical approval was obtained from VA Boston Institutional Review Board. Conclusion: Telehealth-supported exercise represents a promising method for improving survivorship care for veterans with lung cancer and other diverse oncology populations.

Background: In 2016, the US Department of Veterans Affairs (VA) implemented a national initiative to distribute video-enabled tablets and peripheral devices, such as blood pressure monitors and weighing scales, to patients facing geographic, clinical, or socioeconomic challenges. Such patients could potentially benefit from health monitoring in conjunction with video-based care, as peripheral devices offer opportunities to enrich care received during a video visit and support tracking of health-related data collected outside of clinical care, or patient-generated health data. However, little is known about experiences with the devices and how they could support improved access to care. Objective: We explored patients’ experiences with VA-issued peripheral devices and their impact on video-based care and health monitoring outside of clinical visits. Methods: We conducted in-depth semistructured interviews among patients who received VA-issued tablets and peripheral devices between 2023 and 2024. Purposive sampling was used to gather views based on gender, age, race or ethnicity, and rurality. Interviews were transcribed and analyzed using rapid qualitative analysis, guided by the Unified Theory of Acceptance and Use of Technology. Results: Among 25 patients, most received a blood pressure monitor (21/25, 84%), a weight scale (14/25, 56%), and/or a pulse oximetry device (12/25, 48%). The majority reported using their peripheral devices (23/25, 92%) and tablets (19/25, 76%) to monitor their vital signs and attend video visits. Qualitative analysis yielded ten themes reflecting experiences and impacts of the devices, organized by the Unified Theory of Acceptance and Use of Technology constructs: “effort expectancy” consisted of (1) familiar and easy to use devices and (2) challenges of Bluetooth pairing and measurement; “performance expectancy” consisted of (3) integration with video visits, (4) health monitoring for peace of mind, (5) perceptions of improved vital signs and lifestyle behaviors, (6) removing obstacles to in-person care, and (7) desiring an overall picture of health; “social influence” consisted of (8) fostering care team connections and (9) promoting awareness of tablets and peripheral devices; and “facilitating conditions” consisted of (10) supportive help desk infrastructure. Overall, patients described using peripheral devices during virtual visits by syncing data to the tablet for real-time access by their care team. They also reported manually tracking and sharing patient-generated health data with their care team. Despite some challenges with Bluetooth pairing, patients found the devices easy to use and contributed to improved health and motivation. Devices also reduced logistical burdens of in-person visits, especially for those with limited mobility, visual impairments, mental health needs, or transportation barriers. Conclusions: Patients perceive that peripheral devices can enhance video-based care and support health care access and chronic disease management. Patients reported benefits to health, behavior, and communication with care teams. To maximize the impact, program enhancements should prioritize device interoperability, accessible training, and expanded outreach.

Background: The integration of patient-generated health data (PGHD) into health care has the potential to significantly transform patient care and clinical practice. PGHD includes health-related data created by patients, enabling the collection of health data beyond traditional health care settings. The Veterans Health Administration (VA) has taken proactive steps to incorporate PGHD into health care through its Share My Health Data (SMHD) mobile app. Launched in 2023, the SMHD app allows veterans to securely share data from their personal digital health devices with the VA for clinical and research use. However, data characterizing patients who use such tools in real-world health care systems are lacking, creating an evidence gap for implementing PGHD-informed care equitably. Objective: This study aimed to identify the characteristics of patients using the VA SMHD mobile app, which allows veterans to share PGHD with the VA. Methods: We conducted a cross-sectional analysis of veterans who began using SMHD between October 2023 and September 2024 (n=3157, “SMHD users”). We collected demographic information, including age, sex, race/ethnicity, and rurality, and clinical information, including physiological and mental health conditions, from VA administrative data. We compared characteristics of SMHD users to a 10% random sample of veterans from the same underlying administrative data cohort that had never used the app (n=632,187, “nonusers”). Statistical analyses were performed using chi-square tests, independent t tests, and multivariable regression to assess the relationship between use and key characteristics. Results: Middle-aged veterans were more likely to be SMHD users (40-49 years: odds ratio [OR] 1.55, P<.001; 50-59 years: OR 1.37, P<.001), while veterans aged 60 years and over were less likely (60-69 years: OR 0.72, P<.001; ≥70 years: OR 0.24, P<.001). Female (OR 1.23, P<.001) and married (OR 1.31, P<.001) veterans were more likely to be SMHD users than male and unmarried veterans. In contrast, Black or African American (OR 0.62, P<.001) and rural (OR 0.82, P<.001) veterans were less likely to be SMHD users than White and urban veterans. Veterans in higher-income zip codes (OR 1.36, P<.001) were more likely to have used the app than those in lower-income zip codes. Clinically, SMHD users were more likely to have a service-connected disability (OR 1.81, P<.001), multiple physiological conditions (OR 1.86, P<.001), and multiple mental health diagnoses (OR 1.35, P<.001) versus none. Conclusions: Veterans who used the SMHD app differed significantly from nonusers across several demographic and clinical characteristics. These insights identify specific demographic and clinical subgroups with higher and lower app adoption, providing an evidence base to inform targeted implementation and outreach and support strategies to promote enhanced engagement in PGHD-informed care.

Background: The Veterans Health Administration is promoting patient-reported outcome measure (PROM) collection for measurement-based mental health care. Understanding veteran preferences about how and when to complete PROMs is critical to support their implementation. Objective: We examined veteran preferences for timing and use of different technology platforms to complete mental health–related PROMs. Methods: We invited a national sample of 1373 veterans to complete a survey; 858 (62.5%) responded. Surveys asked about veteran preferences for how and when to complete mental health–related PROMs. We characterized responses using descriptive statistics and estimated multiple logistic regression models to examine associations between veteran demographic and health characteristics and preferences for completing PROMs. Results: Most veterans preferred completing PROMs between appointments (607/801, 75.8%) using features of a patient portal (410/801, 51.2%), during appointments (589/801, 73.5%) verbally (413/801, 51.6%), and while at the medical center (480/801, 59.9%) on paper (189/801, 23.6%) or a tablet computer (180/801, 22.5%). Hispanic (vs non-Hispanic) veterans had 3.32 (95% CI 1.04-10.58) times higher odds of preferring to complete PROMs at the medical center, and veterans with lower (vs higher) socioeconomic status had lower odds (odds ratio 0.61, 95% CI 0.40-0.93) of preferring to complete PROMs in between appointments but 1.97 (95% CI 1.23-3.16) times higher odds of preferring to complete PROMs during appointments. Conclusions: As the Veterans Health Administration and other health care systems seek to expand the integration of PROM data into health care services, adaptive and flexible approaches to PROM administration that align with patient preferences, including those that leverage technology platforms in the remote collection of these data, may bolster implementation. Our results indicate that such implementation efforts should consider patient ethnicity and socioeconomic status. Our findings further suggest that these efforts could benefit from incorporating PROM administration into online patient portals, developing mobile health apps that support PROM completion through patients’ personal devices in between clinical encounters, and engaging care team members in PROM administration during appointments.

Background: Uncontrolled diabetes contributes to serious comorbidities and mortality. Effective self-management can improve outcomes, though barriers such as limited education and support often prevent patients from engaging in such behaviors. Automated texting systems show promise to deliver diabetes self-management education as they are accessible and scalable. Furthermore, customizing these systems may further enhance patient engagement compared to standard, one-size-fits-all approaches. However, such customization is more resource-intensive, and it remains unclear whether the added effort meaningfully enhances diabetes self-management and outcomes. Objective: This study aimed to describe the development of 2 versions of an automated texting system intervention for diabetes self-management: (1) a standard, education-only intervention (Diabetes Self-Management Support; DSMS) and (2) an interactive, customizable intervention (Diabetes Self-Management Support + Interactive and Customizable Messages; DSMS+). Methods: Two versions of an automated texting system intervention were developed using a participatory design approach that incorporated input from veterans and expert clinicians. Message content was refined through feedback from a multidisciplinary team, veteran coinvestigators, national surveys, interviews, clinical expert panel reviews, and beta testing. Surveys were mailed to 1000 potential participants, oversampling rural, low-income, minority, and female participants. Respondents rated message relevance and provided preferences for content, timing, and frequency. Interviews provided customization preferences. A clinical expert panel reviewed all messages for safety and appropriateness. Beta testing informed final refinements. Results: Ninety-two surveys were completed (9.2% response rate). Respondents rated 62% of the messages as personally relevant and 61% confidence-enhancing. Interviews with 23 respondents revealed a preference for 1-2 texts per day, emphasizing topics such as healthy eating and weight management. The clinical expert panel reviewed 536 messages, flagging 81 for revision. Beta testing confirmed feasibility and informed refinements to clarity and timing. The 2 resulting interventions were built in the US Department of Veterans Affairs’ automated texting system, Annie. Conclusions: Two text messaging interventions, DSMS and DSMS+, were developed to support diabetes self-management among US veterans. DSMS delivers standard educational content, while DSMS+ incorporates interactive features and personalization. The subsequent clinical trial will assess whether customization enhances engagement and improves diabetes outcomes, providing insights into the potential of tailored mobile health interventions for chronic disease management.

BACKGROUND In 2016, the US Department of Veterans Affairs (VA) implemented a national initiative to distribute video-enabled tablets and peripheral devices, such as blood pressure monitors and weighing scales, to patients facing geographic, clinical, or socioeconomic challenges. Such patients could potentially benefit from health monitoring in conjunction with video-based care, as peripheral devices offer opportunities to enrich care received during a video visit and support tracking of health-related data collected outside of clinical care, or patient-generated health data. However, little is known about experiences with the devices and how they could support improved access to care. OBJECTIVE We explored patients’ experiences with VA-issued peripheral devices and their impact on video-based care and health monitoring outside of clinical visits. METHODS We conducted in-depth semistructured interviews among patients who received VA-issued tablets and peripheral devices between 2023 and 2024. Purposive sampling was used to gather views based on gender, age, race or ethnicity, and rurality. Interviews were transcribed and analyzed using rapid qualitative analysis, guided by the Unified Theory of Acceptance and Use of Technology. RESULTS Among 25 patients, most received a blood pressure monitor (21/25, 84%), a weight scale (14/25, 56%), and/or a pulse oximetry device (12/25, 48%). The majority reported using their peripheral devices (23/25, 92%) and tablets (19/25, 76%) to monitor their vital signs and attend video visits. Qualitative analysis yielded ten themes reflecting experiences and impacts of the devices, organized by the Unified Theory of Acceptance and Use of Technology constructs: “effort expectancy” consisted of (1) familiar and easy to use devices and (2) challenges of Bluetooth pairing and measurement; “performance expectancy” consisted of (3) integration with video visits, (4) health monitoring for peace of mind, (5) perceptions of improved vital signs and lifestyle behaviors, (6) removing obstacles to in-person care, and (7) desiring an overall picture of health; “social influence” consisted of (8) fostering care team connections and (9) promoting awareness of tablets and peripheral devices; and “facilitating conditions” consisted of (10) supportive help desk infrastructure. Overall, patients described using peripheral devices during virtual visits by syncing data to the tablet for real-time access by their care team. They also reported manually tracking and sharing patient-generated health data with their care team. Despite some challenges with Bluetooth pairing, patients found the devices easy to use and contributed to improved health and motivation. Devices also reduced logistical burdens of in-person visits, especially for those with limited mobility, visual impairments, mental health needs, or transportation barriers. CONCLUSIONS Patients perceive that peripheral devices can enhance video-based care and support health care access and chronic disease management. Patients reported benefits to health, behavior, and communication with care teams. To maximize the impact, program enhancements should prioritize device interoperability, accessible training, and expanded outreach. CLINICALTRIAL

Patient messaging technologies offer treatment information and recommendations through web-based platforms, patient portals, mobile apps, and SMS text messaging. Many of these technologies have started to incorporate messages that are crafted by artificial intelligence (AI). Such tools are most effective when constructed with theoretical grounding and iterative input from end users. Thus, we outline a human-centered design approach for developing patient messaging content that aligns with self-determination theory (SDT), a widely used framework that has shown positive impacts on health behavior change. We illustrate our approach step-by-step for the development of messages that promote evidence-based treatment opportunities for patients with chronic pain. Messages were initially developed by subject matter experts and refined using SDT constructs (autonomy, competence, and relatedness) and motivation and behavior change techniques. Using a rapid prototyping approach, we sequentially met with 3 patient engagement boards to elicit feedback on message prototypes and enhance their content. We synthesized and aligned disparate feedback across boards with SDT and motivation and behavior change techniques. Drawing upon the input from the engagement boards, existing co-design approaches, and the field of human-centered AI, we recommend strategies to collaborate with patient partners to enhance the readability and clarity of messaging content. Recommended strategies include (1) involve engagement boards early in messaging framing and modality selection, (2) represent diverse perspectives when refining messages, (3) acknowledge and set expectations to integrate unique experiences and views, (4) prioritize message tailoring for the population of interest, (5) incorporate continual feedback mechanisms, and (6) keep the human interaction in patient-facing messages. By illuminating the process of developing message content that aligns with SDT constructs and providing guidance for iterative patient engagement and practical prototyping, we hope this tutorial can be used to enhance patient messaging content and improve uptake of evidence-based treatments. Our approach and recommendations can also guide multidisciplinary research and design teams to build patient-centered health messages. This tutorial has special consideration for future AI-guided messaging interventions, as patients are typically not involved in message content development or framing, but early engagement can potentially mitigate known AI concerns related to privacy, transparency, and fairness. As technologies and patient populations change over time, linking continual end user input with theoretical grounding plays a key role in simplifying complex medical information and promoting understanding of treatment opportunities that can ultimately improve health outcomes.

Background: The COVID-19 pandemic led to increased demand for remote management of type 2 diabetes using secure messaging, or patient-provider text-based communication. Prior research on secure messaging has described the content of messages sent for type 2 diabetes management and demonstrated its impact on clinical outcomes. However, there is a gap in knowledge about how secure messaging performs as a communication medium for specific tasks in clinical care (eg, prescription management and discussing medical questions). Additional research is needed to understand physicians’ experiences using secure messaging to communicate with patients about clinical tasks that support diabetes management. Objective: This study aims to investigate physicians’ experience using secure messaging to communicate with patients about specific clinical tasks for type 2 diabetes management. Methods: We interviewed a sample of endocrinologists and internists from 2 different medical facilities who have used secure messaging to communicate with adult patients about type 2 diabetes management. Semistructured interviews were used to solicit physicians’ experience using secure messaging for 6 specific tasks that support diabetes management: refilling prescriptions, answering nonurgent medical questions, scheduling appointments, discussing test results, making referral requests, and discussing visit follow-up. Interviews were conducted until we achieved saturation of themes for these tasks. Interview data were collected between 2021 and 2023. Qualitative data were analyzed using the framework method for thematic analysis. Results: We interviewed 6 internists and 4 endocrinologists (n=10). Physicians reported spending between 2 and 5 hours per day messaging with patients. They observed that secure messaging increased the frequency and timeliness of communication, which improved care coordination and facilitated care delivery between visits. This served as a time-efficient way to iterate specific components of treatment plans, including discussing test results, visit follow-up, scheduling, and prescription refill. Physicians were frustrated with the unstructured nature of secure messages. Patients wrote messages that were often disorganized, confusing, or did not have enough information for the provider to take action. This often made answering nonurgent medical questions difficult. In many cases, poorly structured secure messages resulted in lengthy back-and-forth communications between patients and physicians, which sometimes required a phone call or an office visit to resolve. Conclusions: Physicians reported that secure messaging supports a longitudinal model of care, where patients can iterate their treatment plan between visits. For tasks with well-defined information boundaries, such as scheduling and prescription refill, physicians reported that secure messaging improved the time efficiency of care delivery. Providers experienced challenges using secure messaging for more complex tasks and often reported not receiving sufficient clinical information. We identified a demand for workflow technologies to process incoming secure messages to improve clarity and ensure that messages have sufficient information to inform decisions on the best course of action.

BACKGROUND Uncontrolled diabetes contributes to serious comorbidities and mortality. Effective self-management can improve outcomes, though barriers such as limited education and support often prevent patients from engaging in such behaviors. Automated texting systems show promise to deliver diabetes self-management education as they are accessible and scalable. Furthermore, customizing these systems may further enhance patient engagement compared to standard, one-size-fits-all approaches. However, such customization is more resource-intensive, and it remains unclear whether the added effort meaningfully enhances diabetes self-management and outcomes. OBJECTIVE This study aimed to describe the development of 2 versions of an automated texting system intervention for diabetes self-management: (1) a standard, education-only intervention (Diabetes Self-Management Support; DSMS) and (2) an interactive, customizable intervention (Diabetes Self-Management Support + Interactive and Customizable Messages; DSMS+). METHODS Two versions of an automated texting system intervention were developed using a participatory design approach that incorporated input from veterans and expert clinicians. Message content was refined through feedback from a multidisciplinary team, veteran coinvestigators, national surveys, interviews, clinical expert panel reviews, and beta testing. Surveys were mailed to 1000 potential participants, oversampling rural, low-income, minority, and female participants. Respondents rated message relevance and provided preferences for content, timing, and frequency. Interviews provided customization preferences. A clinical expert panel reviewed all messages for safety and appropriateness. Beta testing informed final refinements. RESULTS Ninety-two surveys were completed (9.2% response rate). Respondents rated 62% of the messages as personally relevant and 61% confidence-enhancing. Interviews with 23 respondents revealed a preference for 1-2 texts per day, emphasizing topics such as healthy eating and weight management. The clinical expert panel reviewed 536 messages, flagging 81 for revision. Beta testing confirmed feasibility and informed refinements to clarity and timing. The 2 resulting interventions were built in the US Department of Veterans Affairs’ automated texting system, Annie. CONCLUSIONS Two text messaging interventions, DSMS and DSMS+, were developed to support diabetes self-management among US veterans. DSMS delivers standard educational content, while DSMS+ incorporates interactive features and personalization. The subsequent clinical trial will assess whether customization enhances engagement and improves diabetes outcomes, providing insights into the potential of tailored mobile health interventions for chronic disease management.

BACKGROUND The Veterans Health Administration is promoting patient-reported outcome measure (PROM) collection for measurement-based mental health care. Understanding veteran preferences about how and when to complete PROMs is critical to support their implementation. OBJECTIVE We examined veteran preferences for timing and use of different technology platforms to complete mental health–related PROMs. METHODS We invited a national sample of 1373 veterans to complete a survey; 858 (62.5%) responded. Surveys asked about veteran preferences for how and when to complete mental health–related PROMs. We characterized responses using descriptive statistics and estimated multiple logistic regression models to examine associations between veteran demographic and health characteristics and preferences for completing PROMs. RESULTS Most veterans preferred completing PROMs between appointments (607/801, 75.8%) using features of a patient portal (410/801, 51.2%), during appointments (589/801, 73.5%) verbally (413/801, 51.6%), and while at the medical center (480/801, 59.9%) on paper (189/801, 23.6%) or a tablet computer (180/801, 22.5%). Hispanic (vs non-Hispanic) veterans had 3.32 (95% CI 1.04-10.58) times higher odds of preferring to complete PROMs at the medical center, and veterans with lower (vs higher) socioeconomic status had lower odds (odds ratio 0.61, 95% CI 0.40-0.93) of preferring to complete PROMs in between appointments but 1.97 (95% CI 1.23-3.16) times higher odds of preferring to complete PROMs during appointments. CONCLUSIONS As the Veterans Health Administration and other health care systems seek to expand the integration of PROM data into health care services, adaptive and flexible approaches to PROM administration that align with patient preferences, including those that leverage technology platforms in the remote collection of these data, may bolster implementation. Our results indicate that such implementation efforts should consider patient ethnicity and socioeconomic status. Our findings further suggest that these efforts could benefit from incorporating PROM administration into online patient portals, developing mobile health apps that support PROM completion through patients’ personal devices in between clinical encounters, and engaging care team members in PROM administration during appointments.