Encouraging Patient-Centered Communication in Clinical Video Telehealth Visits

Background: Clinical video telehealth (CVT) offers the opportunity for more efficient access
to high quality primary and specialist care for Veterans. Enthusiasm for CVT is especially
high in the VA given geographical separation between many Veterans and their providers at VA
Medical Centers. However, because CVT encounters are by nature less personal than in-person
visits, communication during CVT visits may be more challenging for both patients and
providers resulting in less patient-centered communication. Less personal visits may have
less exchange of information, lower satisfaction, less trust, and poorer outcomes. Indeed,
research comparing CVT with in-person consultations found that patients in CVT visits were
more passive and that CVT interactions were dominated by providers when compared with
in-person visits.

This project will leverage prior work from two HSR&D-funded pilot projects to improve
provider - patient communication for Veterans with type 2 diabetes mellitus. In a short-term
project, SHP-08-182, the investigators conducted focus groups to elicit and understand
patients' barriers to communicating with their providers. This qualitative work was used in a
subsequent pilot project, PPO-08-402 to develop an educational video to encourage Veterans to
use active participatory communication in their visits to providers. This work was
successfully completed and the product is a 10-minute video that, in testing, was found to be
acceptable and feasible to show to VA patients immediately preceding their medical
encounters.

Objectives: The investigators goal in this project is develop and test a video intervention
and to also develop pamphlets for patients and providers to encourage active and positive
communication in CVT medical interactions. The investigators goal was developed with and is
supported by the project's operational partner the Office of Telehealth Services and is
integral to the goal to ensure patient-centered care in new models of care. Patient-centered
communication in medical interactions is critical and plays an important, but often
overlooked, role in the delivery of health services.

There are two aims. First, the investigators will develop educational interventions to
encourage patients and providers to use active communication behaviors during CVT visits.
Second, the investigators will conduct a randomized trial of the video and pamphlet
(intervention) vs. pamphlet alone (comparison) in a two-arm randomized effectiveness trial.
The investigators will evaluate for improvement in visit outcomes including patient and
provider measures of patient-centered care and communication, reduction in several common
barriers to clinical improvement, and improved medication adherence measures and hemoglobin
A1c. In addition, the investigators will assess the mediators and moderators of the
relationship of the intervention condition to outcomes.

Methods: The project will have two phases. In the initial phase of the proposed project the
investigators will develop the video intervention. Video development will include qualitative
interviews with stakeholders and patients regarding CVT barriers and perceived benefits. The
investigators will use several existing resources and an expert panel of co-investigators and
consultants to bring these elements together and produce the intervention. In phase 2 the
investigators will conduct a randomized trial of the intervention, evaluating for improvement
in a number of outcomes.

Impacts: The educational tools will be deliverables that could be used prior to CVT visits to
improve communication and could serve as a paradigm for developing communication aids for
other medical conditions and other clinical settings. The investigators will evaluate whether
the educational intervention will help improve communication and will be associated with
better visit and intermediate outcomes. Educational tools that encourage more
patient-centered communication during CVT encounters may allow more rapid acceptance of CVT,
thereby improving access to healthcare and enhancing the operational mission of the project's
partner.

Inclusion Criteria:

- Diagnosis of type 2 diabetes mellitus,

- Hemoglobin A1c not controlled,

- Adults,

- Age 18 or older

Exclusion Criteria:

- Dementia,

- Lives in skilled nursing facility,

- Terminal medical condition,

- Drug-induced diabetes,

- Blind or deaf.