Kenneth R. Weingardt

Embracing a Health Services Research Perspective on Personal Health Records: Lessons Learned from the VA My HealtheVet System

BackgroundPersonal health records (PHRs) are designed to help people manage information about their health. Over the past decade, there has been a proliferation of PHRs, but research regarding their effects on clinical, behavioral, and financial outcomes remains limited. The potential for PHRs to facilitate patient-centered care and health system transformation underscores the importance of embracing a broader perspective on PHR research.ObjectiveDrawing from the experiences of VA staff to evaluate the My HealtheVet (MHV) PHR, this article advocates for a health services research perspective on the study of PHR systems.MethodsWe describe an organizing framework and research agenda, and offer insights that have emerged from our ongoing efforts regarding the design of PHR-related studies, the need to address PHR data ownership and consent, and the promotion of effective PHR research collaborations.ConclusionThese lessons are applicable to other PHR systems and the conduct of PHR research across different organizational contexts.

Training Research: Practical Recommendations for Maximum Impact

This review offers practical recommendations regarding research on training in evidence-based practices for mental health and substance abuse treatment. When designing training research, we recommend: (a) aligning with the larger dissemination and implementation literature to consider contextual variables and clearly defining terminology, (b) critically examining the implicit assumptions underlying the stage model of psychotherapy development, (c) incorporating research methods from other disciplines that embrace the principles of formative evaluation and iterative review, and (d) thinking about how technology can be used to take training to scale throughout all stages of a training research project. An example demonstrates the implementation of these recommendations.

A Randomized Trial Comparing Two Models of Web-Based Training in Cognitive Behavioral Therapy for Substance Abuse Counselors

This study compared training outcomes obtained by 147 substance abuse counselors who completed eight self-paced online modules on cognitive-behavioral therapy (CBT) and attended a series of four weekly group supervision sessions using Web conferencing software. Participants were randomly assigned to two conditions that systematically varied the degree to which they explicitly promoted adherence to the CBT protocol and the degree of control that they afforded participants over the sequence and relative emphasis of the training curriculum. Outcomes were assessed at baseline and immediately following training. Counselors in both conditions demonstrated similar improvements in CBT knowledge and self-efficacy. Counselors in the low-fidelity condition demonstrated greater improvement on one of three measures of job-related burnout when compared to the high-fidelity condition. The study concludes that it is feasible to implement a technology-based training intervention with a geographically diverse sample of practitioners, that two training conditions applied to these samples of real-world counselors do not produce statistically or clinically significant differences in knowledge or self-efficacy, and that further research is needed to evaluate how a flexible training model may influence clinician behavior and patient outcomes.

A randomized controlled trial of telephone motivational interviewing to enhance mental health treatment engagement in Iraq and Afghanistan veterans.

OBJECTIVE To test the efficacy of telephone-administered motivational interviewing (MI) to enhance treatment engagement in Iraq and Afghanistan veterans with mental health (MH) problems. METHOD Between April 23, 2008, and February 25, 2011, 73 Iraq and Afghanistan veterans who screened positive for ≥1 MH problem(s) on telephone-administered psychometric assessment, but were not engaged in treatment, were randomized to either personalized referral for MH services and four sessions of telephone MI or standard referral and four neutral telephone check-in sessions (control) at baseline, 2, 4 and 8 weeks. Blinded assessment occurred at 8 and 16 weeks. RESULTS In intent-to-treat analyses, 62% assigned to telephone MI engaged in MH treatment compared to 26% of controls [relative risk (RR)=2.41, 95% confidence interval (CI)=1.33-4.37, P=.004], which represented a large effect size (Cohens h=0.74). Participants in the MI group also demonstrated significantly greater retention in MH treatment than controls [MI mean visits (S.D.)=1.68 (2.73) and control mean visits (S.D.)=0.38 (0.81), incidence rate ratio (IRR)=4.36, 95% CI=1.96-9.68, P<.001], as well as significant reductions in stigma and marijuana use at 8 weeks (P<.05). CONCLUSIONS Telephone MI enhances MH treatment engagement in Iraq and Afghanistan veterans with MH problems.

Technology-Based Training in Cognitive Behavioral Therapy for Substance Abuse Counselors

Abstract This study compared the learning outcomes achieved by 166 practicing substance abuse counselors who were randomized to one of three conditions: (1) a Web-Based Training (WBT) module designed to familiarize practitioners with the “Coping with Craving” module from the NIDA treatment manual, “A Cognitive-Behavioral Approach: Treating Cocaine Addiction” (www.nidatoolbox.org), (2) a face-to-face training workshop covering the identical content, or (3) a delayed training control condition. Participants in all three conditions completed an identical test of knowledge before and after the session. Results indicated that participants in both the WBT and face-to-face workshop conditions showed improvement in mean test scores, while participants in the delayed training control condition did not. Improvements in test scores for participants in both the WBT and face-to-face conditions were statistically significant and equally modest in magnitude. The finding of equivalent rates of knowledge transfer across these two delivery mechanisms highlight one function for which WBT may be particularly well-suited, and suggest that the most effective clinical training applications may use a “blended delivery” format that leverages the strengths of both WBT and face-to-face training.

IntelliCare: An Eclectic, Skills-Based App Suite for the Treatment of Depression and Anxiety

Background Digital mental health tools have tended to use psychoeducational strategies based on treatment orientations developed and validated outside of digital health. These features do not map well to the brief but frequent ways that people use mobile phones and mobile phone apps today. To address these challenges, we developed a suite of apps for depression and anxiety called IntelliCare, each developed with a focused goal and interactional style. IntelliCare apps prioritize interactive skills training over education and are designed for frequent but short interactions. Objective The overall objective of this study was to pilot a coach-assisted version of IntelliCare and evaluate its use and efficacy at reducing symptoms of depression and anxiety. Methods Participants, recruited through a health care system, Web-based and community advertising, and clinical research registries, were included in this single-arm trial if they had elevated symptoms of depression or anxiety. Participants had access to the 14 IntelliCare apps from Google Play and received 8 weeks of coaching on the use of IntelliCare. Coaching included an initial phone call plus 2 or more texts per week over the 8 weeks, with some participants receiving an additional brief phone call. Primary outcomes included the Patient Health Questionnaire-9 (PHQ-9) for depression and the Generalized Anxiety Disorder-7 (GAD-7) for anxiety. Participants were compensated up to US

Health-Related Internet Use in Older Primary Care Patients

90 for completing all assessments; compensation was not for app use or treatment engagement. Results Of the 99 participants who initiated treatment, 90.1% (90/99) completed 8 weeks. Participants showed substantial reductions in the PHQ-9 and GAD-7 (P<.001). Participants used the apps an average of 195.4 (SD 141) times over the 8 weeks. The average length of use was 1.1 (SD 2.1) minutes, and 95% of participants downloaded 5 or more of the IntelliCare apps. Conclusions This study supports the IntelliCare framework of providing a suite of skills-focused apps that can be used frequently and briefly to reduce symptoms of depression and anxiety. The IntelliCare system is elemental, allowing individual apps to be used or not used based on their effectiveness and utility, and it is eclectic, viewing treatment strategies as elements that can be applied as needed rather than adhering to a singular, overarching, theoretical model. Trial Registration Clinicaltrials.gov NCT02176226; http://clinicaltrials.gov/ct2/show/NCT02176226 (Archived by WebCite at http://www.webcitation/6mQZuBGk1)

Client predictors of treatment retention and completion in a program for homeless veterans.

Background: Adults aged 65 years and older stand to benefit from the accumulating wealth of Internet-based health resources, including online interventions to assist in the self-management of chronic health conditions. However, concerns have been expressed that lesser Internet use and familiarity among older adults may limit the utility of web-based health interventions in older age groups. As these interventions become more prevalent, it is important to understand older adults’ receptivity to using the Internet as a tool in managing healthcare. Objective: The purpose of the present study was to gauge the extent to which older primary care patients are receptive to using web-based health resources, and to explore how health-related Internet use may be related to patient characteristics such as age, income, and health and mental health status. Methods: We surveyed 50 adults aged 65 years and older in a Veterans Administration primary care clinic regarding: (1) Internet use for any purpose, (2) Internet use to obtain health or mental-related information, and (3) interest in using Internet-based interventions to address various health-related needs. A substantial proportion of respondents were in their 70s, 80s, and 90s, and many had multiple medical conditions. Results: Nearly three-quarters of older primary care patients in our sample were regular Internet users and over half had experience in using the Internet to search for health information. The majority of Internet users endorsed an interest in using web-based resources to manage various aspects of their health and mental healthcare. Conclusions: Our results support the conclusion that older primary care patients, including those among the oldest-old and those with multiple medical conditions, are amenable to using the Internet as a means of enhancing healthcare.

Characterizing binge drinking among U.S. military Veterans receiving a brief alcohol intervention

This study assessed the value of a specific set of client variables in predicting treatment retention and completion of a rehabilitation program for homeless veterans. Participants were 596 (22 female) military veterans admitted to the Palo Alto, California Veterans Administration domicilary program between 1992 and 1995. Information was collected on a number of demographic and background characteristics previously used to predict treatment retention and outcomes. Results indicated that clients who were younger, female, and currently diagnosed with a depressive disorder, showed the highest rates of treatment retention and completion, whereas a current personality disorder diagnosis or history of psychiatric treatment was related to poorer rates of retention and completion. These results may be informative for identifying ways to modify this and other similar treatments to apply to a larger client population. The studys limitations were noted.

How Internet Technology Can Improve the Quality of Care for Substance Use Disorders

BACKGROUND Brief web-based alcohol interventions (BAIs) are effective for reducing binge drinking in college students and civilian adults, and are increasingly being applied to U.S. military populations. However, little is known about factors associated with binge drinking in Veteran populations and therefore some concern remains on the generalizability of studies supporting BAIs for addressing binge drinking in this population. This study sought to better understand the characteristics (e.g., demographic, coping related mental health factors, prior exposure to traumatic events, and factors assessing motivation to change alcohol use) of a predominantly male sample of binge drinking Veterans receiving a BAI from a VA provider. METHODS A primarily male (93.5%) sample (N=554) of Veterans completed a BAI consisting of brief assessment and personalized feedback. RESULTS We found that Veterans who were younger, used drugs/alcohol to cope with symptoms of PTSD and depression (e.g., nightmares and flashbacks and sleep difficulties), and had experienced sexual assault, had higher self-reported peak blood alcohol concentration and a higher likelihood for a binge drinking episode in the last 90days. CONCLUSIONS BAIs may be a promising approach for addressing binge drinking in Veterans. However, binge drinking among a sample of mostly male Veterans receiving a BAI may be associated with a complex set of factors that are less prevalent in the college student population and thus studies demonstrating the efficacy of BAIs with Veterans are needed.