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Abstract

Background:

The TeleWound Practice Program (TWP) is an evidence-based, coordinated national effort to deliver technology-enabled wound care services to Veterans with chronic wounds. To inform implementation across the Veterans Health Administration (VHA), we used the Practical, Robust Implementation and Sustainability Model (PRISM) to examine Veteran and TeleWound health care provider perspectives of the TWP to identify early lessons learned.

Methods:

We conducted semistructured interviews informed by the PRISM with Veterans who received TWP care and TWP providers, investigating experiences with and perceptions of TeleWound care and the perceived impact of the TWP on patient outcomes. We used PRISM constructs to organize emerging themes to describe patient- and provider-level factors relevant to implementation.

Results:

Fifteen Veterans and seven providers participated. Both Veterans and providers reported positive experiences, to date, with the TWP and saw many tangible benefits associated with its implementation, including improved Veteran access to high-quality wound care and more efficient, convenient care with fewer costs incurred by both Veterans and the VHA health care system. Both groups suggested that preparing Veterans for TWP encounters was critical. Despite many common themes between Veterans and providers, we learned of several unmet needs and suggestions unique to the Veteran or provider experience. Veterans noted that their unique clinical needs were not always met or easily accounted for through the TWP’s remote modalities, highlighting a need for technical support. Providers reported that increased administrative burden and lack of buy-in among leadership and other providers impeded implementation.

Conclusion:

Findings suggest that it will be essential to (1) acknowledge and build on patients’ and providers’ positive experiences with TWP; (2) address Veteran-level needs and suggestions, and consider individual clinical needs and preferences when deciding if TWP is the best approach for their wound care; and (3) address unmet provider-level needs (e.g., securing leadership buy-in) to support implementation.

Keywords

Veteran health wound care access to care telehealth implementation science

Introduction

The presence of chronic wounds, or open wounds that have not progressed through normal healing processes within a month,^1,2 predicts mortality more than heart disease, peripheral arterial disease, or stroke.³ Treating chronic wounds requires ongoing, specialized care, including frequent assessment and therapy, prevention, and long-term follow-up to achieve healing.^4,5 For many wound care programs, however, addressing the logistical demands to fulfill these needs is challenging, potentially leading to poor outcomes including amputation and lower quality of life.^6–8 Individuals living in rural areas may experience additional barriers to accessing specialized wound care.^9,10 These issues point to a need to expand access to high-quality, specialized wound care that streamlines care delivery and aligns with patient and provider needs. The urgency to expand wound care access continues to grow, moreover, as the burden of chronic wounds and their corresponding costs—for both health care systems and patients—continues to rise substantially given an aging population with a high prevalence of chronic comorbidity.¹¹

One promising solution is to carefully incorporate telehealth technology into wound care delivery. Highlighted by the system-wide Diffusion of Excellence (DoE) program within the Veterans Health Administration (VHA),¹² the TeleWound Practice Program (TWP) represents an evidence-based, coordinated national effort to standardize and clinical training and documentation while enhancing collaboration across teams that care for Veterans with chronic wounds. The TWP, also known as the No Wound Left Behind initiative, leverages technology-enabled wound care services to expand care access while minimizing patient-level travel burden and infection risk.^13,14 Wound care services delivered through TWP can entail real-time virtual visits using clinical video telehealth (CVT) or Veterans Affairs (VA) Video Connect (VVC) between a wound care specialist at a VHA hospital facility and a Veteran patient in either their home or a VHA community-based outpatient clinic setting. The TWP also extends to asynchronous telehealth care, known as store-and-forward telehealth (SFT), where a patient can submit a photograph of their wound for a specialist to review.¹⁵ TWP implementation began in 2019 at a regional level across four VHA hospitals to deliver virtual wound care, particularly for Veterans in rural communities.

Early evidence suggests that the TWP has been successful in decreasing travel burden and increasing satisfaction among Veterans. Additional findings suggest TWP use may be associated with fewer limb amputations, emergency visits and hospital admissions, shorter lengths of stay, and, consequently, lower costs.^16,17 Although our prior work found that tele-wound care outcomes are comparable to in-person care,⁷ successfully expanding TWP—and understanding its impact—requires a more in-depth view into the perspectives of Veteran patients and health care providers who have interacted with the program. As part of a broader evaluation effort to inform the scale-up of TWP implementation across the VHA health care system,¹⁵ we used the Practical, Robust Implementation and Sustainability Model (PRISM) conceptual framework to examine Veteran and TeleWound health care provider perspectives of the TWP and identify early lessons learned for implementation.

Methods

We conducted this qualitative project as part of a broader mixed-methods, quality improvement (QI) evaluation of the TWP in partnership with the VHA Diffusion of Excellence (DOE) office, which is leading implementation efforts, along with the VHA National Podiatry Office, the VHA National Spinal Cord Injuries and Disorders Program Office, the VHA Office of Nursing Services, and the VHA Office of Connected Care—Telehealth Services. In this article, we focus only on the qualitative aspects of the evaluation that were relevant to TWP implementation from patient and provider perspectives. Further details on the TWP evaluation efforts are published elsewhere.^15,18 We used the Consolidated Criteria for Reporting Qualitative Research (COREQ) guideline to report key study details.¹⁹ This work was reviewed by the Edward Hines VA Hospital Institutional Review Board and designated as program evaluation for QI, exempting it from further oversight (VHA Handbook 1058.05).

Conceptual framework

We used the PRISM to frame our evaluation efforts.²⁰ Frequently used in eHealth-related research and program evaluations, the PRISM proposes that successful implementation of evidence into practice is a function of four broad and interrelated elements: (1) the intervention, (2) intervention recipients (e.g., patients, clinical health care providers), (3) implementation and sustainability infrastructure, and (4) the broader environment surrounding the intervention (Fig. 1).²⁰ PRISM’s elements follow the widely used Reach, Effectiveness, Adoption, Implementation, Maintenance framework, highlighting a need to assess key multilevel contextual factors influencing the reach, effectiveness, adoption, implementation, and maintenance outcomes of health interventions.²¹ As described in prior research,²² we used the PRISM to develop operational definitions of its elements tailored to the TWP and mapped to our data sources (Table 1). To capture Veteran and health care provider perspectives on the implementation of the TWP and perceived factors influencing implementation, these operational definitions informed qualitative data collection and analysis for our Veteran and health care provider interviews.

FIG. 1.

Original PRISM figure.²⁰ PRISM, Practical, Robust Implementation and Sustainability Model.

Table 1.

PRISM Operational Definitions and Types of Data Collected

PRISM Element	PRISM Subelement	Operational Definition for TeleWound Practice Program (TWP)	Data Source
The intervention (i.e., TWP Program)	Organizational perspective of the intervention	Health care provider perspectives on the evidence base for the intervention, potential barriers to frontline health care providers, and the usefulness of the intervention to the local context	Health care provider interviews
The intervention (i.e., TWP Program)	Patient perspective of the intervention	Veteran perspectives on key intervention components, and initial reactions to the program	Veteran interviews
Intervention recipients	Organizational characteristics	The dynamic between teams, the financial and structural health of the organization, organizational culture, and the history of trying or resisting new programs	Health care provider interviews
Intervention recipients	Patient characteristics	Veteran demographics, competing programs and demands on the Veterans, and stories of care from Veterans that may affect their view of the TWP	Veteran interviews/demographic questionnaire
External environment	N/A	Current regulatory environment and community services/demographics may impact the organizational culture and/or implementation and sustainability of the intervention	Health care provider interviews
Implementation and sustainability infrastructure	N/A	Relationship and communication between individuals in the infrastructure, implementation infrastructure, routine performance measurement, and data sharing for longer-term maintenance of intervention	Health care provider interviews

Data collection

We conducted in-depth, one-on-one, and semistructured interviews with Veterans who responded to the Veteran survey from the broader TWP evaluation and agreed to participate in a more detailed interview regarding their experience with TeleWound care. Similarly, we conducted in-depth, one-on-one, semistructured interviews with TWP health care providers who responded to the provider survey and agreed to participate in the subsequent interview. We also used snowball sampling to identify additional providers and facility leadership to invite to participate in the interviews.²³

Interviews were between 30 and 45 min long, audio-recorded, and transcribed to support qualitative data analysis. For Veterans, the interviews further explored the topics covered in the survey, including their experiences with and perceptions of TeleWound care and the perceived impact of TeleWound care on outcomes such as wound self-management. For health care providers, we focused on understanding their frontline experiences and perceptions of the TWP, perceived barriers and facilitators to its implementation, and suggestions to both embed TeleWound care into routine clinical practice at their own VHA facility and expand it to other VHA facilities. We developed patient and provider interview guides based on a review of relevant literature on wound care delivery/access and the elements encompassed within PRISM, along with input from the study team members, all of whom have experience with qualitative methods and research focused on telehealth care delivery, Veteran health, and VHA specialty care. All participants completed a questionnaire to obtain basic demographic information prior to their interview, and for Veterans, information about their wound locations and experiences with TeleWound care.

Data analysis

Interview recordings were transcribed verbatim to ensure transcription accuracy. We first used an inductive approach and the constant comparative technique to organize the content into categories, identifying common and unique themes across interviews²⁴ to develop a preliminary coding scheme. Three team members trained in qualitative methods (M.W., J.P., S.N.B.) independently coded the interview transcripts such that each interview was coded by ≥2 study members. We focused on characterizing participant perspectives on the potential advantages (i.e., perceived benefits) and disadvantages (i.e., perceived drawbacks or other negative outcomes) of TWP, implementation barriers and facilitators, and practical suggestions to optimize implementation and sustainability infrastructure and capacity in the future. As in prior studies,²⁵ we then used the PRISM elements to organize our emerging themes. Discrepancies were reconciled through consensus. Coded transcripts were analyzed within and across cases to develop themes.

Results

In total, n = 15 Veterans and n = 7 providers participated in the qualitative interviews, out of a possible total of 25 Veterans and 14 providers, respectively. All Veterans were male and, on average, 74 years old (SD: 9.1; range: 46–87). Veterans reported that their wounds were related to ulcers, sores, amputations, ostomies, and other surgical wounds, predominantly on their feet, legs, and buttocks. Among TWP modalities, most Veterans reported using VVC alone, and a smaller proportion reported using CVT only, SFT only, or a combination of CVT, SFT, and/or VVC. One Veteran reported receiving educational materials ahead of the TeleWound encounter designed to guide patients through the program’s logistical steps. Among the Veterans who reported technical issues during a TeleWound encounter (n = 6), half described challenges with audio and/or visual clarity during the encounter, and the other half described problems or delays in connecting remotely for their encounter. Health care providers included four advanced practice nurses, two telehealth clinical technicians, and one facility telehealth coordinator, all of whom had prior, first-hand experience with the TWP. Participant characteristics are presented in Table 2.

Table 2.

Participant Characteristics

Veterans (N = 15)	Mean ± SD or Frequency (%)
Age (years)	74.0 (9.1)
Sex
Male	15 (100)
Wound location
Buttock	4 (26.7)
Foot/Ankle	4 (26.7)
Leg	4 (26.7)
Abdomen	3 (20)
Back	2 (13.3)
TeleWound modality used
VVC only	7 (46.7)
CVT only	3 (20)
Combination of CVT, SFT, and/or VVC	2 (13.3)
SFT only	1 (6.7)
Missing	1 (6.7)
Educational material received before TeleWound encounter	1 (6.7)
Veterans experiencing technical issues during TeleWound encounter	6 (42.9)
Types of technical issues
Audio/Visual clarity	3 (50)
Delay or challenges in connecting	3 (50)

Health Care Providers (N = 7)	Mean ± SD or Frequency (%)
Age (years)	47.9 (8.4)
Sex
Female	6 (85.7)
Male	1 (14.3)
VHA service
<6 years	0
6–10 years	1 (14.3)
11–15 years	5 (71.4)
16–20 years	0
>20 years	1 (14.3)
Title/Position
Advanced practice nurse (APN), Clinical nurse specialist (CNS), or Nurse practitioner (NP)	4 (57.1)
Telehealth clinical technician (TCT)	2 (28.6)
Facility telehealth coordinator (FTC)	1 (14.3)

CVT, clinical video telehealth; SFT, store-and-forward telehealth; VHA, Veterans Health Administration; VVC, Veterans Affairs Video Connect.

We organized themes according to PRISM elements and subelements, delineating each theme as a perceived advantage or disadvantage surrounding the TWP, implementation barrier or facilitator, or a practical suggestion/strategy to optimize implementation and sustainability moving forward. To highlight perspectives of the TWP that were either shared between Veterans and health care providers, or unique to one stakeholder group, we then grouped all themes into three broad categories: (1) themes derived from Veteran- and health-care-provider-reported data; (2) themes derived solely from Veteran-reported data; and (3) themes derived solely from health-care-provider-reported data. Emerging themes are denoted in bolded text in this section.

Category 1: Themes mapped to the PRISM, based on Veteran and health care provider data

We identified several themes that describe Veteran and health care provider perspectives that were shared, or overlapping, across both stakeholder groups. Table 3 includes representative quotes related to each theme in this category.

Table 3.

Category 1: Emerging Qualitative Themes Mapped to the PRISM Elements and Subelements, Based on Veteran and Health Care Provider Data

PRISM Element	PRISM Subelement	Theme	Representative Quote
The intervention (TWP Program)	Organizational perspective of the intervention	Advantage: TWP increases efficiency and convenience	“In the case of limited mobility and difficulty with access to transportation, even [for] a guy that’s in a metropolitan [city], instead of them coming weekly in in heavy traffic and the freeway and trying to drive, and they’re in their power chair… it’s difficult. And so, if they can save some trips in by using VVC and sending images in, that’s another outcome that’s positive. It improves their quality of life.” [Provider]
		Advantage: TWP improves access to high-quality care	“We had a patient that came here for wound care. We got them to a certain point, and then we’re following up with the same system. [A spoke site] is going to see what we did in [our site], I’m going to be able to see what they did in, say, [city, state], and it will just provide a better, seamless integration of care between different sites.” [Provider]
		Advantage: TWP helps reduce costs	“With rural Veterans and maybe a bunch of people… especially through COVID, but even before that, like [for] our rural Veterans and with spinal cord [injury], it’s so difficult to get transportation there and—so it saves money, so it’s cost effective for the VA.” [Provider]
		Advantage: TWP promotes patient engagement in care	“My patients love seeing the images. When we do wound rounds in patients, they’re ready for ‘Hey, is [name] coming too?’ They want to see the progress. They’re actually excited about it. So, they get more buy-in, the patients. They’re more compliant. So that’s part of a better outcome. You’re improving their quality of life.” [Provider]
	Patient perspective of the intervention	Advantage: TWP increases efficiency and convenience	“It’s a good way for the VA to be able to see more patients in a day. There’s less time spent on just waiting and stuff like that. So if they can see more patients in a day that’s better for all Veterans.” [Veteran]
		Advantage: TWP improves access to high-quality care	“I see no denigrations in the care that I’m getting just because we’re doing it on video.” [Veteran]
		Advantage: TWP helps reduce costs	“[TeleWound] is just like being there only you don’t have to be there so you save a lot of money on expenses.” [Veteran]
		Advantage: TWP promotes patient engagement in care	“Once a week I’ll take a picture of my wound and send it in. She can look at it and say, ‘Oh yeah, it looks like it’s doing this or do we want to do that.’ It’s more interactive in the wound care itself. It gets the patient more involved with wound care than [leaving] everything to the doctor.” [Veteran]
Intervention recipients	Organizational characteristics	None reported by both groups
Intervention recipients	Patient characteristics	Facilitator: Usability of TWP technology	“Anybody that can answer an email should be able to log in and just hit the button and then ask if you want to connect and you say yes.” [Veteran]
External environment	N/A	None reported by both
Implementation and sustainability infrastructure	N/A	Suggestion: Better prepare Veterans for TWP encounters	“There should be like a little fact sheet or something like ‘this is what you need to do.’” [Provider]

The intervention

We found that Veterans and health care providers participating in this project shared a closely aligned view of the intervention (the TWP) and that satisfaction with their TWP-related experiences was high. In terms of the PRISM subelement, organizational perspective of the intervention, health care providers reported several key advantages they felt were associated with TWP, including increasing efficiency and convenience, improving access to high-quality care, helping to reduce costs, and promoting patient engagement in their own care. Similarly, Veterans reported many of the same advantages within the corresponding patient-level PRISM subelement patient perspective of the intervention. Veterans (8/15) and health care providers (7/7) both stated, for example, that implementation of the TWP increases efficiency and convenience, particularly for Veterans living with limited mobility or limited access to transportation, who could potentially see their wound care provider(s) for a clinic visit in a quicker, easier way when using TWP as compared with a traditional in-person visit. In addition, both groups felt that the TWP enhanced efficiency and convenience at the VHA system level because TeleWound appointments allow for more streamlined scheduling/coordination of care (i.e., more Veterans seen in a given day and less time spent on wait times, travel, or other logistical considerations).

Veterans (10/15) and health care providers (6/7) also felt that the TWP improves access to high-quality care, often reflecting that they saw no major differences in the perceived quality of wound care whether conducted in person or through the TWP. Health care providers further commented that the TWP enabled more seamless follow-up and coordination of care for patients who might be seen across different VHA hub and spoke facilities.

Relatedly, both Veterans (12/15) and health care providers (7/7) felt that the TWP helps to reduce costs both for Veterans and the VHA system more broadly. Veterans reflected that remote TeleWound appointments were “just like being [at the VHA]” from a care perspective, and that avoiding a potential commute to a VHA facility resulted in saved money that might have been spent on travel-related costs. Health care providers similarly commented that these savings also extended to the VHA at a system level, particularly in cases of rural Veterans with disabilities, who may receive reimbursement from VHA for health-related travel costs but could now be seen in a more cost-effective manner through the TWP.

Finally, Veterans (7/15) and health care providers (5/7) both felt that the TWP promotes patient engagement in care, enabling patients to routinely photograph their own wound, upload the photograph ahead of a TeleWound visit, and monitor the progress of wound healing alongside their providers. Both groups described this as an interactive opportunity for patients to play an active role in the care process, which health care providers felt also contributed to improved patient compliance with treatment plans.

Intervention recipients

In terms of patient characteristics, a subelement of PRISM’s intervention recipients element, we learned that both Veterans (11/15) and health care providers (6/7) felt that usability of the TWP technology was an important facilitator at the patient level to its implementation. Both groups described the TWP technology as “simple” and “user-friendly,” commenting that most Veterans, especially those who are able to use basic web-based functions should be able to use the TWP technology without substantial difficulty.

Implementation and sustainability infrastructure

Both stakeholder groups shared one practical suggestion to optimize implementation and sustainability of the TWP moving forward: each group articulated a need to better prepare Veterans for their TWP encounters. Most Veterans (12/15) stated that they did not receive educational materials in advance of an appointment to inform them about the logistical steps of a TeleWound encounter and how care may compare or contrast with an in-person visit. This observation is also reflected in the brief demographic questionnaire that Veterans completed ahead of their interview (Table 1). To address this and ensure that TeleWound encounters move smoothly, Veterans and health care providers both felt that it is essential for Veterans to receive brief educational materials (e.g., a short fact sheet or troubleshooting information related to TWP appointments) ahead of their encounter.

Category 2: Themes mapped to the PRISM, based on Veteran data only

We identified several additional themes that were derived solely from Veteran interviews and, conversely, were not reflected in health care provider interviews. Table 4 includes representative quotes related to each theme in this category.

Table 4.

Category 2: Emerging Qualitative Themes Mapped to the PRISM Elements and Subelements, Based on Veteran Data Only

PRISM Element	PRISM Subelement	Theme	Representative Quote
The intervention (TWP Program)	Patient perspective of the intervention	Facilitator: Ordering supplies	“[My TWP provider] said, ‘I will order these supplies that you need’ and then I didn’t have to go through my primary care doctor and all of that hassle. There was no hassle. She just ordered them.” [Veteran]
Intervention recipients	Patient characteristics	Disadvantage: TWP may not account for Veterans’ unique clinical needs	“When [my providers] touch a wound they can tell if it’s tender. They can’t tell that over video. They couldn’t see the drainage because it takes 2–3 days for it to drain. And they couldn’t see the specific colors, or smell whether it had an odor... In my case it wasn’t healing.” [Veteran]
External environment	N/A	Barrier: Technical issues	“The second time, the video didn’t work. Why? I’m not sure. Obviously, that was a problem.” [Veteran]
Implementation and sustainability infrastructure	N/A	Suggestion: Consider individual needs and preferences when deciding if TWP is the best approach for a given patient	“Everything depends on the status of your wound. If I’m having a heck of a time with my wound, if I’m in pain, then I want an in-person face-to-face visit.” [Veteran]
Implementation and sustainability infrastructure		Suggestion: Address Veterans’ technical support needs so TWP encounters go smoothly	“Make it easy to connect. Remember, a lot of older Vets, especially, don’t have as much technology as I have. I have a smart phone.” [Veteran]

The intervention

With regard to the patient perspective of the intervention, many Veterans reflected on the overarching TWP as a seamless new approach to obtaining wound care. Besides enabling remote wound care appointments, this approach, in Veteran’s views, also helped with managing other wound care needs. For example, Veterans (6/15) stated that their TeleWound provider would often assist, during a TWP encounter, with ordering wound care supplies. Veterans felt that this was a facilitator to using TWP and appreciated that their wound care supplies could be seamlessly ordered by their provider during an encounter, making a potentially challenging process more convenient for them.

Intervention recipients

In line with the PRISM’s patient characteristics subelement, several Veterans (6/15) reported that their unique clinical needs, as the recipients of the intervention, were not always met or easily accounted for in the TWP’s remote modalities. Veterans reflected on the heterogeneous and complex nature of chronic wounds (i.e., there is a wide range of wound types, and a need for individualized evaluation, monitoring, and treatment from wound to wound). In-person individualized evaluation and wound monitoring were particularly important to this group of Veterans, who felt that in-person approaches (vs. those using TWP) can be more reliable to detect any changes in size, color, tenderness, drainage, or other wound care outcomes.

External environment

One barrier to use of the TWP reported by Veterans, falling into the external environment subelement, related to technical issues surrounding the TWP encounter. As reflected in our brief demographic questionnaire (Table 1), several Veterans (6/15) experienced technical issues that impeded their TeleWound care encounter, including delays or challenges in connecting with the wound care provider using the TWP technology and lack of audio or visual clarity during the encounter.

Implementation and sustainability infrastructure

We found that Veterans recommended two practical suggestions (that were not articulated by health care providers) to optimize implementation and sustainability of the TWP moving forward. The first of these suggestions was to consider the individual needs and preferences of Veterans when deciding if the TWP is the best approach for a given Veteran at that point in time. In addition to some Veterans stating that wound healing progress (or lack thereof) was, at times, more difficult over TWP, Veterans (5/15) commented that the decision to move forward with a TeleWound versus an in-person encounter would ideally account for the status of the wound along with the Veteran’s own preferences.

The second practical suggestion emerging from the Veteran interview data was to address Veterans’ technical support needs so that TWP encounters proceed smoothly. Building on the barrier Veterans described (re: technical issues impeding TWP use), Veterans (9/15) described a need to carefully assess—and address—the technical support needs that an individual Veteran may face. Veterans noted that the comfort level and familiarity with technology often vary widely among Veterans. To that end, Veteran interviewees suggested that it is imperative that (1) the TWP technology is easy to use and user-friendly for Veterans and that (2), if needed, additional facilitation or technical support should be available to help Veterans navigate and use the TWP technology.

Category 3: Themes mapped to the PRISM, based on health care provider data only

In this final category, we present themes that we derived solely from health care provider interviews and, conversely, were not reflected in Veteran interviews. Table 5 includes representative quotes related to each theme in this category.

Table 5.

Category 3: Emerging Qualitative Themes Mapped to the PRISM Elements and Subelements, Based on Health Care Provider Data Only

PRISM Element	PRISM Subelement	Theme	Representative Quote
The intervention (TWP Program)	Organizational perspective of the intervention	Advantage: TWP enhances continuity of care	“If I’ve taken care of a patient for a year, which happens in spinal cord because we have these huge wounds, I can go back a year and I can see what that wound looked like, and I can see the progression.” [Provider]
		Disadvantage: TWP increases workload for providers	“We have 13 different disciplines, so I’m running around a lot. And right now, even though we’ve done TeleWound, I’m behind in putting encounters in. The workload is pretty heavy to do TeleWound.” [Providers]
		Barrier: Initial TWP setup is challenging	“The initial pain of changing over [to TWP] is worth it. Some facilities… said it was too difficult.” [Provider]
Intervention recipients	Organizational characteristics	Barrier: Lack of buy-in to support uptake of TWP	“We only have one wound provider, a nurse practitioner, on [site], which is anywhere from an hour to two and a half hours from the different CBOCs. [The wound care provider] is not big on [telehealth].” [Provider]
Intervention recipients	Organizational characteristics	Suggestion: Secure a local champion to support implementation	“You need someone with enthusiasm about it that can teach them how to chart properly, that can teach them how to use TeleWound properly.” [Provider]
External environment	N/A	Facilitator: Partner with other VHA services to streamline implementation	“The Clinical Resource Hub that we work with for primary care and mental health providers… is onboarding a nurse practitioner for wound.” [Provider]
Implementation and sustainability infrastructure	N/A	Suggestion: Improve equipment access and technical training for providers	“If the [techs] are trained and we have the correct equipment and the wound provider is willing to do CVT and work with them, I don’t see why [the visit] couldn’t happen virtually.” [Provider]
Implementation and sustainability infrastructure	N/A	Suggestion: Obtain leadership buy-in to promote implementation	“If we could get a few providers to start doing it and get buy-in with the new Clinical Resource Hub nurse practitioner, wound care nurse practitioners, the Chief of Staff for primary care, we could probably get more consults and start letting them see: ‘Hey, this works.’” [Provider]

CBOC, community-based outpatient clinic.

The intervention

As part of the organizational perspective of the intervention subelement, we found that three themes emerged when health care providers reflected on their experiences with wound care delivery and their views of the TWP. First, most health care providers (5/7) believed that a key advantage of the TWP is that it enhances continuity of care. The nature of chronic wound care, health care providers commented, often involves monitoring and treating patients’ wounds for an extended time period. Health care providers felt that this was especially relevant for their patients with spinal cord injuries and disabilities, who are more susceptible to large, complicated wounds that can require consistent monitoring. Health care providers reported that the infrastructure of the TWP technology helped to conveniently document providers’ notes and patients’ wound images from past encounters.

Second, health care providers (4/7) highlighted their view that one disadvantage related to the TWP is that it increases provider workload. Health care providers stated that, in most cases, executing TeleWound encounters contributed to an increase in their time spent on clinical documentation and administrative tasks. Consequently, some reported feeling behind with TeleWound-related documentation or administrative tasks and struggling to keep up with those tasks in a timely manner.

Third, health care providers reflected on their early experiences with adopting the TWP, stating that one barrier to implementation was that the initial setup for the TWP was challenging. Health care providers (4/7) noted that the preparation to begin seeing patients through the TWP was cumbersome and involved substantial administrative burden, particularly to change current practices and begin using the TWP technology. Health care providers suggested that this barrier may discourage some VHA facilities from implementing the TWP, although they believed the challenges surrounding initial setup were short-term and ultimately beneficial to improve wound care.

Intervention recipients

Health care providers also discussed that a lack of buy-in (related to the TWP intervention) among wound care providers represented a barrier to implementation. This lack of buy-in, in health care providers’ view, often entailed a lack of interest or intent among wound care providers to adopt the TWP as part of their routine practice. Health care providers (5/7) commented that, at their facility, this lack of buy-in contributed at times to a wound care provider shortage within the TWP program, potentially limiting the number of Veterans who could be seen for wound care needs.

To address this barrier and help with broader TWP implementation, health care providers (3/7) noted another practical suggestion to secure a local champion to support TWP implementation: it was important for an individual at each VHA facility to share their enthusiasm for the TWP, educate other providers at that facility on the benefits and best practices related to the TWP, and, finally, help train on steps to prepare for and carry out a TeleWound encounter.

External environment

Related to the external environment surrounding the intervention, health care providers (2/7) shared that one key facilitator that streamlined their implementation of the TWP was to partner with other VHA services. As an example, health care providers specifically highlighted VHA Clinical Resource Hubs (CRHs) and their programs as a strategy to increase Veteran access to VHA telehealth and in-person clinical services. Health care providers noted that CRHs have been helpful in their past experiences to better connect Veterans with access to primary care and mental health providers, and that they were now being used effectively to increase access to wound care providers via the TWP.

Implementation and sustainability infrastructure

Health care providers discussed two practical suggestions to optimize TWP implementation and sustainability infrastructure in the future. These suggestions included a need to improve equipment access and technical training for providers using the TWP and a need to obtain leadership buy-in to promote TWP implementation. Health care providers (6/7) noted that having access to equipment and the corresponding provider training/education to carry out TeleWound care appointments was an important prerequisite to TWP implementation. In their view, ensuring that wound care providers have access to TWP-related equipment as well as provider training/education was critical to improve, and ultimately expand, TWP implementation. Finally, building on their earlier comments about securing a local champion, health care providers (4/7) commented that obtaining buy-in from relevant leadership would also help support implementation.

To triangulate themes specifically addressing practical implementation suggestions that emerged from the interviews with Veterans, health care providers, or both, we present these themes in Figure 2 according to the stakeholder group(s) that reported them (Veterans, health care providers, or both).

FIG. 2.

Suggestions to optimize TWP implementation and sustainability infrastructure, reported by Veterans, health care providers, or both.

Discussion

We leveraged the strengths of qualitative research methods^26,27 and the well-established PRISM²¹ framework to evaluate Veteran and health care provider perceptions and early experiences surrounding VHA’s TWP. In triangulating Veteran and health care provider viewpoints, we learned that both groups had largely positive experiences with the TWP and saw many tangible benefits associated with its implementation, including improved Veteran access to high-quality wound care, as well as more efficient, convenient care with fewer costs incurred by both Veterans and the VHA health care system. Our practical lessons learned underpin a novel contribution that expands the current evidence base on wound care management using telehealth technologies: despite high satisfaction and many overlapping themes between Veterans and TeleWound health care providers, we identified several unmet needs and suggestions that were unique to either the Veteran experience (e.g., considering individual wound care needs/preferences when deciding if the TWP is the best approach) or the TWP health care provider experience (e.g., securing leadership buy-in to support implementation). Acknowledging Veteran and health care providers’ positive experiences and areas of alignment while addressing these Veteran- and health-care-provider-level needs will be critical to inform the broader rollout of the TWP in a way that brings together patients, providers, and system leaders in a partnered effort to optimize access to high-quality wound care.

Ensuring that Veterans have timely access to care through ‘any door’ is a priority for VHA.²⁸ Wound care is one area where this priority is particularly relevant given that (1) the burden of chronic wounds is substantially greater—and more complex—among Veterans than the general population, in part due to combat injuries and comorbid chronic health conditions,^29–31 and (2) because timely wound evaluation and early intervention are essential to avoid a complicated clinical trajectory characterized by worsening quality of life and escalating morbidity and costs.^32,33 This overarching backdrop helps to contextualize our findings, reminding us that the primary intent behind the TWP is to improve access to timely, high-quality wound care. Without question, the TWP initiative supports VHA priorities in this area by creating a standardized, system-wide structure to bring timely wound care to Veterans wherever they are.³⁴ Our qualitative findings validate the early successes of telehealth-based wound care documented by our team⁷ and others^35–38 and delineate several potential targets for future improvement.

In a study of leg and foot ulcers in Norway, Blytt et al. highlighted the importance of aligning delivery of virtual wound care with nurse and patient perspectives.³⁹ In a setting of limited prior qualitative investigation, our findings meaningfully expand on this, helping to unpack the nuances at the patient and provider level that influence TeleWound uptake—beyond leg and foot ulcers—and outlining actionable steps to move implementation forward. As the TWP initiative expands nationally, our findings can be used to refine implementation efforts, for example, by reducing administrative burden for providers associated with the TWP and increasing leadership support. To ensure patient-centeredness, it will also be imperative, as our findings suggest, to consistently incorporate the individual needs and preferences of Veterans—both from a clinical care and technical support standpoint—into wound care. VHA has built a successful, longstanding track record of applying its telehealth modalities, including VVC and CVT, to improve care access across a wide range of clinical specialties such as dermatology, spinal cord injury, mental health, and primary care.^40–42 Many of these initiatives are well-received by Veterans^43,44 and, in some cases, more established from an implementation and dissemination perspective compared with the TWP.^45–50 It will be important to consider what lessons can be learned from VHA’s telehealth efforts in these other clinical settings and, more importantly, what tailored adaptations could be developed to enhance TWP implementation.

As TWP implementation advances, providers, researchers, and system leaders should also keep in mind known challenges surrounding telehealth^51,52 and the extent to which they may manifest in the TWP setting. Our findings briefly touched on one such challenge, most often referred to as the “digital divide,”⁵³ suggesting that TeleWound care may not be a prudent wound care option for Veterans who may be less comfortable using technology, including telehealth technology platforms. These findings reinforce the importance of providing concrete support for patients who may have less developed digital and telehealth skills and using telehealth visits to identify patients who may require in-person care.^54,55

We found it useful in our analysis to describe perspectives of TWP implementation that were unique to or shared between Veteran and health care provider groups: both interact with the intervention and have a role to play in its implementation. Individuals in these groups naturally see different angles of implementation, all of which provide practical insights for future efforts. Using the PRISM was especially relevant in recognizing the discrete roles that patients and providers play and bringing them together to map out future implementation steps. Beyond ensuring that the unique clinical needs of Veterans with chronic wounds are accounted for in TWP implementation, it will also be critical to address health-care-provider-level barriers to implementation, such as increases in workload or lack of buy-in.

Pragmatic approaches are needed that acknowledge these real-world challenges and lean in not only to implementation science principles, such as those at the heart of PRISM, but also perhaps to QI principles. Although implementation science, as the study of systematic uptake of evidence-based interventions into practice, is a distinct field compared with QI, both implementation science and QI share an overlapping goal to drive or evaluate system-level change in health care practice.^56–58 This overlap has been previously recognized in a variety of clinical settings, including among Veterans, and can help to define strategies to scale up interventions that effectively improve care quality and outcomes.^59–62 Adapting TWP implementation efforts to leverage established QI methodologies—such as continuous evaluation and feedback and localized support—could be a helpful strategy to promote implementation with the ultimate goal of embedding the TWP into routine practice.

This work has limitations. Our findings may not represent the larger population of Veterans with chronic wounds or wound care providers and may not translate to other clinical settings or populations, including individuals with (or delivering care for) chronic wounds in the general population.¹¹ As described in existing methodological literature, however, the goal of qualitative inquiry is, often, to investigate discrete phenomenon in-depth and not to generalize broadly to larger populations.⁶³ To this end, smaller sample sizes are appropriate if thematic saturation is reached.^63,64 Future research should include a greater focus on gathering views of a broader representation of Veterans with chronic wounds and other providers who play essential roles in wound care.

Conclusion

Despite many common themes between Veterans and TeleWound health care providers, there exist several unmet needs and suggestions that are unique to either the Veteran or TeleWound health care provider experience. Findings suggest that it will be essential to (1) acknowledge and build on Veteran and health care provider positive experiences with the TWP; (2) address Veteran-level needs and suggestions and consider individual clinical wound needs and preferences, when deciding if TWP is the best approach; and (3) address unmet health-care-provider-level needs, such as securing leadership buy-in to support implementation. As implementation of the TWP expands across the VHA health care system, future research should focus on characterizing Veteran-, health-care-provider-, and system-level factors that most significantly influence implementation, and ultimately, wound care outcomes.

Footnotes

Authorship Contribution Statement

S.N.B., B.E., and F.M.W. designed the study. M.W., J.P., B.M.S., T.P.H., K.S., B.E., and F.M.W. were involved in the acquisition of the data. S.N.B., M.W., J.P., B.E., and F.M.W. analyzed and interpreted the data. S.N.B. drafted the article and made all revisions recommended by coauthors. All authors critically reviewed the article and approved the final version of this article.

Ethics Approval and Consent to Participate

This work was reviewed by the Institutional Review Board at the Edward Hines Junior VHA Hospital in Hines, IL, and was designated as a program evaluation for QI purposes, exempting it from further oversight (VHA Handbook 1058.05).

Consent for Publication

This article does not require consent for publication.

Availability of Data and Materials

The datasets generated and/or analyzed during the current study are not publicly available due to institutional restrictions.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This program evaluation was funded in October of 2019 as a Partnered Evaluation Initiative by the US Department of Veterans Affairs, Diffusion of Excellence Office, Office of Research and Development, Health Services Research and Development Service, and Quality Enhancement Research Initiative (QUERI) Program (PEC 19-310). The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the US government.

Abbreviations

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Patient and Health Care Provider Perspectives of Virtually Delivered Wound Care: Early Lessons Learned to Optimize Implementation

Abstract

Background:

Methods:

Results:

Conclusion:

Keywords

Introduction

Methods

Conceptual framework

Data collection

Data analysis

Results

Category 1: Themes mapped to the PRISM, based on Veteran and health care provider data

The intervention

Intervention recipients

Implementation and sustainability infrastructure

Category 2: Themes mapped to the PRISM, based on Veteran data only

The intervention

Intervention recipients

External environment

Implementation and sustainability infrastructure

Category 3: Themes mapped to the PRISM, based on health care provider data only

The intervention

Intervention recipients

External environment

Implementation and sustainability infrastructure

Discussion

Conclusion

Footnotes

Authorship Contribution Statement

Ethics Approval and Consent to Participate

Consent for Publication

Availability of Data and Materials

Author Disclosure Statement

Funding Information

Abbreviations

References