BACKGROUND:While telehealth has potential to enhance patients' access to care, uneven implementation may limit its impact. My VA Images (MVAI), a clinician-gated, patient-facing asynchronous teledermatology application developed by the Department of Veterans Affairs (VA) was piloted at three VA facilities, and then sequentially offered to groups of seven facilities every 3 months for 1 year. We characterized patients who were exposed to and used MVAI and we identified associated characteristics. METHODS:We used VA's mobile health and administrative databases to examine MVAI activity and dermatology patient demographics over a 17-month period during 2019 and 2020. RESULTS:At 11 VA facilities, 494 established dermatology patients were invited to a follow-up visit using MVAI. Invitees were more likely than Non-Invitees to be White and urban, have shorter drive times to specialty care, and have more outpatient and dermatology visits before and after MVAI use. Forty-eight percent of Invitees successfully used MVAI and were most likely to do so in the 8-30 day interval. Successful Users were more likely than Unsuccessful Users to be younger and have a dermatology visit 1 year after MVAI use. Patients requiring multiple attempts before successfully using MVAI were older than initially Successful Users, though younger than Unsuccessful Users. CONCLUSIONS:Not all patients benefited equally during the initial rollout of MVAI. Disparities in VA where other forms of patient-facing telehealth are already common illustrate challenges for health care organizations in equitably implementing direct-to-patient teledermatology. Specific groups may benefit from targeted outreach or support.

Home-based teledermatology and artificial intelligence (AI) are current and emerging tools for delivering skin care whose effectiveness partly depends on patients who are willing to use them. To assess willingness in patients, we randomly surveyed 10,013 Veterans who had received outpatient dermatologic care from October 2021-September 2022. 1,881 respondents answered every question regarding willingness on a scale from 1 (very unwilling) to 5 (very willing). Factor analysis of responses yielded single factor (mean score 3.6) and three-factor solutions corresponding to willingness for skin care by: 1) Home-based teledermatology (mean=3.6); 2) PCPs guided by a smart computer (mean=3.8); and 3) Smart computer-guided self-care (mean=3.5). The desire to avoid travel for skin care contributed the least to willingness to use technology. Multiple linear regression identified younger age and confidence in filling out medical forms (a surrogate for health literacy) to be consistently associated with greater willingness to use technology for skin care, while living with someone, financial security, and education beyond high school were variably associated with willingness. The results indicate that Veteran dermatology patients have modest willingness to use home-based teledermatology and AI for their skin care, and may be most willing to receive care from PCPs guided by AI.

Background:The U.S. Veterans Health Administration (VHA) formed an Innovation Ecosystem that develops and disseminates innovative practices to enhance Veterans' health. Support of senior leadership and their perception of the innovation process is key to the Ecosystem's success. We aimed to elicit insights on (1) how national VHA program office leaders define innovation, and (2) important considerations in facilitating the adoption of innovations. Methods:As part of a quality improvement initiative, we conducted 19 semi-structured interviews via teleconference. Interviews involved 4 administration offices, 7 clinical and population health program offices, and 8 policy and quality improvement offices; 12 of these offices reported experience working with the Innovation Ecosystem. Responses were audio recorded, transcribed, and analyzed using constructs from the Consolidated Framework for Implementation Research. Results:Participants generally agreed that innovation within VHA is defined by evidence-based development and implementation of interventions that improve response to Veterans' needs. Considerations in facilitating innovations include: (1) implementation climate that promotes network-building, open communication, and well-executed planning processes; (2) implementation infrastructures that enable engagement with key players and augment existing resources; and (3) innovation evidence strength and responsiveness to patient needs. Individuals working in policy-related offices were more likely to identify complexity, leadership engagement, culture and available resources as factors in choosing innovations to adopt. Individuals who reported experience of working with the Ecosystem emphasized the importance of intra-organizational networks and a favorable implementation climate, while those without experience noted the importance of working with external change agents. CFIR 'inner setting' constructs were seen in responses across all categories; meanwhile, emerging constructs highlight how innovation should be balanced by the reality of operations. Conclusions:Among national VHA program office leaders, innovation is pursued to improve Veterans' health. Resources, networks, culture, and processes are considered important factors among program office leaders to support and encourage innovation.

RATIONALE: Artificial intelligence (AI) has the potential to transform healthcare, including cancer care. Yet, many are concerned about real or perceived risks associated with AI – a phenomenon known as the AI trust gap. Addressing all stakeholders’ concerns is essential to bridging the trust gap and leveraging the full potential of AI. This study explores pulmonologists’ perspectives on use of AI in healthcare. METHODS: The Department of Veteran Affairs (VA) developed a trustworthy AI framework with six guiding principles: AI should be purposeful, safe and effective, secure and private, fair and equitable, transparent and explainable, and accountable and monitored. We generated a survey instrument with questions mapped to the AI framework domains, where possible adapting existing survey items identified through a literature search. Five clinical vignettes related to AI use in lung cancer treatment were also developed with the guidance of clinical experts and included in the survey. Each vignette was followed by questions assessing respondents’ receptivity to using AI algorithms for clinical decision support. We then invited fellows and faculty of an academic pulmonary and critical care division to pilot test the online survey to obtain feedback in advance of a national VA survey. Descriptive analyses of responses were calculated using SAS software. RESULTS: Twenty-four of 66 invited pulmonologists participated (36.3% response rate), with fellows and attendings evenly represented. Nearly half (45.8%) reported managing 26-50 patients with lung cancer in the past year. Most used AI daily in personal life (66.7%) and showed more trust than distrust in AI for non-clinical decision-making (41.6% vs. 29.2%). However, 79.2% were unsure or reported not using AI in clinical settings. Across all domains, the strongest concerns were about transparency and the ability to explain results, followed by equity and fairness, and safety and effectiveness. Providers showed slightly more concern than enthusiasm for AI in lung cancer decision making (6.7 vs 5.1). However, 95.8% of providers reported they would seek guidance from AI in lung cancer dilemmas related to imaging and histology. Providers were least likely to use AI in assessing the need for invasive staging (Figure 1), and 83.3% would recommend invasive means contrary to AI. CONCLUSION: This pilot study revealed pulmonologists’ cautious receptivity to AI in lung cancer clinical care, echoing concerns from prior patient and non-pulmonologist provider surveys. A national survey of VA physicians from multiple specialties who manage patients with lung cancer is underway.

Invasive bacterial infections (IBI) associated with drug use are increasing, but the full disease burden remains unknown. We characterized national trends in the prevalence of IBI among veterans with evidence of substance use using a large, national cohort. High rates of IBI highlight a need for more comprehensive infection reduction strategies, including emphasis on gram-negative infections.

People living with HIV and beginning antiretroviral therapy (ART) often struggle with medication adherence and attending appointments due to multi-level challenges such as depression symptoms, substance use, stigma and disclosure, food insecurity, health system challenges, transportation challenges, and gender inequity. The SUSTAIN trial seeks to improve initiation adherence through multiple monitoring and support interventions in three clinics in Mitchells Plain township, Cape Town, South Africa. We qualitatively explored the multi-level challenges impacting adherence at the individual, interpersonal, and structural levels among 60 study participants within the first six months after initiation on ART. The in-depth interview sample was selected purposively based on participant experiences with at least one of these factors reported through a baseline survey, gender, and age. We conducted a content analysis and utilized syndemic theory to understand the synergistic effects of multiple adherence challenges. To manage their HIV diagnosis, participants described positive and negative coping mechanisms, including how substance use affected adherence particularly on big event days (e.g., birthdays, holidays, or funerals). Participants described fears of stigma motivat decisions on disclosure of their HIV status and decreased potential social support, possibly reducing motivation to adhere to ART. Gender inequity reinforced experiences with and perceptions of stigma and disclosure. Participants indicated that food insecurity resulted in feelings of shame when associated with perceived larger appetites due to ART use and with lack of employment. Participants described both positive and negative ways the health system impacted their adherence and retention in care, citing information provided by clinic staff, clinician attitudes, and clinic operations. Misunderstandings regarding the strict timing of ART dose-taking (often from lack of clear information or counselling by clinicians) meant participants often had limited competence to make decisions about their dosing schedule and how to best integrate treatment into their daily lives. Participants described a notable fear of commuting to and from clinics due to dangerous and difficult paths on which muggings occurred frequently; women were at particular risk of violence. Often, participants mentioned multiple factors simultaneously affecting adherence, with additive or synergistic effects. Syndemic factors affecting ART adherence exist across multiple levels. Enhanced adherence counseling, designed as a behavior change intervention, might help PLWH cope with individual adherence barriers and support strategizing about ways to mitigate or overcome structural barriers. Continued efforts by government and implementers to address health system, gender inequity, and security challenges could further support ART adherence.

BackgroundSubstance use is common among U.S. military veterans and veterans are at high risk for negative consequences associated with substance use, such as injection-related infections and overdose. Although harm reduction services (HRS) are highly evidence-based, implementation in traditional healthcare settings has been limited. This formative, qualitative study sought to identify barriers and facilitators to the integration of HRS and identify appropriate implementation strategies to support the optimized integration of a comprehensive bundle of HRS in the Veterans Health Administration (VHA).MethodsSemi-structured interviews explored how harm reduction is currently understood by VHA providers and elicited input on perceived facilitators and barriers to implementation. Data were analyzed using a directed content analysis and the Practical, Robust Implementation and Sustainability Model (PRISM) implementation framework was used to organize findings. Results were then mapped to relevant implementation strategies using the Consolidated Framework for Implementation Research - Expert Recommendations for Implementing Change (CFIR - ERIC) tool.Results15 interviews with VHA providers were conducted across 5 sites. Respondents reported that current HRS are fragmented and dependent on the knowledge, time, and comfort level of individual providers. Stigma around substance use at the patient, provider, and institutional levels was noted to be a key barrier to HRS adoption. Based on identified barriers and facilitators, strategies that may be effective for increasing adoption of HRS include engagement of champions, communication and educational strategies, and adaptation of existing infrastructure.ConclusionsMany of the barriers identified in this formative study may be addressed using evidence-based implementation strategies. Additional research is needed to identify implementation strategies that are effective for addressing stigma, which is perceived to be a persistent challenge to the provision of integrated harm reduction services.

BackgroundSince 2013, the Veterans Health Administration (VHA) has advanced a person-centered, Whole Health (WH) System of Care, a shift from a disease-oriented system to one that prioritizes "what matters most" to patients in their lives. Whole Health is predicated on patient-provider interactions marked by a multi-level understanding of health and trusted relationships that promote well-being. Presently, WH implementation has been focused largely in primary care settings, yet the goal is to effect a system-wide transformation of care so that Veterans receive WH across VHA clinical settings, including specialty care. This sort of system-wide cultural transformation is difficult to implement.MethodsThis three-aim mixed methods study will result in a co-designed implementation blueprint for spreading WH from primary to specialty care settings. Taking HIV specialty care as an illustrative case- because of its diverse models of relationships to primary care - to explore how to spread WH through specialty care settings. We will use the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to organize quantitative and qualitative data and identify key determinants of WH receipt among Veterans living with HIV. Through a co-design process, we develop an adaptable implementation blueprint that identifies and matches implementation strategies to different HIV specialty care configurations.DiscussionThis study will co-design a flexible implementation blueprint for spreading WH from VHA primary care throughout HIV specialty care settings. This protocol contributes to the science of end-user engagement while also answering calls for greater transparency in how implementation strategies are identified, tailored, and spread.

Background Innovative technology can enhance patient access to healthcare but must be successfully implemented to be effective. Objective We evaluated Department of Veterans Affairs’ (VA’s) implementation of My VA Images , a direct-to-patient asynchronous teledermatology mobile application enabling established dermatology patients to receive follow-up care remotely instead of in-person. Design /Participants/Approach Following pilot testing at 3 facilities, the app was introduced to 28 facilities (4 groups of 7) every 3 months using a stepped-wedge cluster-randomized design. Using the Organizational Theory of Implementation Effectiveness, we examined the app’s implementation using qualitative and quantitative data consisting of encounter data from VA’s corporate data warehouse; app usage from VA’s Mobile Health database; bi-monthly reports from facility representatives; phone interviews with clinicians; and documented communications between the operational partner and facility staff. Key Results Implementation policies and practices included VA’s vision to expand home telehealth and marketing/communication strategies. The COVID-19 pandemic dominated the implementation climate by stressing staffing, introducing competing demands, and influencing stakeholder attitudes to the app, including its fit to their values. These factors were associated with mixed implementation effectiveness, defined as high quality consistent use. Nineteen of 31 exposed facilities prepared to use the app; 10 facilities used it for actual patient care, 7 as originally intended. Residents, nurse practitioners, and physician assistants were more likely than attendings to use the app. Facilities exposed to the app pre-pandemic were more likely to use and sustain the new process. Conclusions Considerable heterogeneity existed in implementing mobile teledermatology, despite VA’s common mission, integrated healthcare system, and stakeholders’ broad interest. Identifying opportunities to target favorable facilities and user groups (such as teaching facilities and physician extenders, respectively) while addressing internal implementation barriers including incomplete integration with the electronic health record as well as inadequate staffing may help optimize the initial impact of direct-to-patient telehealth. The COVID pandemic was a notable extrinsic barrier. Clinical Trials Registration NCT03241589

Abstract Background The Veterans Health Administration (VHA) is the United States largest learning health system. The Diffusion of Excellence (DoE) program is a large-scale model of diffusion that identifies and diffuses evidence-informed practices across VHA. During the period of 2016-2021, 57 evidence-informed practices were implemented across 82 VHA facilities. This setting provides a unique opportunity to understand sustainment determinants and pathways. Our objective was to characterize the longitudinal pathways of practices as they transition from initial implementation to long-term sustainment at each facility. Methods A longitudinal, mixed-methods evaluation of 82 VHA facilities. Eighty-two facility representatives, chosen by leadership as points-of-contact for 57 DoE practices, were eligible for post-implementation interviews and annual sustainment surveys. Primary outcomes (implementation, sustainment), and secondary outcomes (institutionalization, effectiveness, anticipated sustainment) at four time-points were collected. We performed descriptive statistics and directed content analysis using Hailemariam et al.’s factors influencing sustainment. Results After approximately five years post-implementation (e.g., 2021 sustainment outcomes), of the 82 facilities, about one-third fully sustained their practice compared to one-third that did not fully sustain their practice because it was in a “liminal” stage (neither sustained nor discontinued) or permanently discontinued. The remaining one-third of facilities had missing 2021 sustainment outcomes. A higher percentage of facilities (70%) had inconsistent primary outcomes (changing over time) compared to facilities (30%) with consistent primary outcomes (same over time). Thirty-four percent of facilities with sustained practices reported resilience since they overcame implementation and sustainment barriers. Facilities with sustained practices reported more positive secondary outcomes compared to those that did not sustain their practice. Key factors facilitating practice sustainment included: demonstrating practice effectiveness/benefit, sufficient organizational leadership, sufficient workforce, and adaptation/alignment with local context. Key factors hindering practice sustainment included: insufficient workforce, not able to maintain practice fidelity/integrity, critical incidents related to the COVID-19 pandemic, organizational leadership did not support sustainment of practice, and no ongoing support. Conclusions We identified diverse pathways from implementation to sustainment, and our data underscore that initial implementation outcomes may not determine long-term sustainment outcomes. This longitudinal evaluation contributes to understanding impacts of the DoE program, including return on investment, achieving learning health system goals, and insights into achieving high-quality healthcare in VHA.

COVID-19 led to a rapid increase in telemental health care via video or phone. It is important to examine contributors to the choice of video versus phone, as video may be more effective and preferred by patients. Medical mental health (MH) providers (e.g., psychiatrists) may conduct more phone and less video visits than nonmedical MH providers (e.g., psychologists). This study examined whether medical and nonmedical providers' perceptions of the quality and complexity of phone and video MH care may contribute to differences in use. A 32-item survey of 414 providers (79.5% response rate) assessed perceptions of care quality, factors contributing to modality choice, and telehealth challenges. The types of visits completed by providers in the months prior to the survey were extracted from administrative data. Medical and nonmedical providers generally viewed video care as higher quality and more preferred than phone, although to a lesser extent among medical providers. Nonmedical providers' decision making was more impacted by research regarding the modalities' relative effectiveness. Medical providers more frequently endorsed video challenges, including patient technical difficulties and lack of patient training. Administrative data demonstrated that medical providers conducted fewer video appointments than nonmedical providers. Medical providers may be less aware of research demonstrating that video care is effective and preferred by patients, and the complexity of video visits may be a barrier to use. Streamlining video processes, increasing technical support, and disseminating research that compares the quality of video and phone care may increase video use among medical providers. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

We conducted qualitative research among people with HIV (PWH) and care providers in Cape Town, South Africa to understand the impact of negative clinic experiences on adherence and support preferences. In-depth interviews were conducted with 41 patients with an unsuppressed viral load or a treatment gap, and focus group discussions with physicians, nurses, counselors, and community health workers. Questions addressed treatment history and adherence barriers, then participants evaluated evidence-based adherence interventions for potential scale up. Inductive analysis examined care experiences and corresponding preference for intervention options. More than half of PWH described negative experiences during clinic visits, including mistreatment by staff and clinic administration issues, and these statements were corroborated by providers. Those with negative experiences in care stated that fear of mistreatment led to nonadherence. Most patients with negative experiences preferred peer support groups or check-in texts to clinic-based interventions. We found that PWH's negative clinic experiences were a primary reason behind nonadherence and influenced preferences for support mechanisms. These findings emphasize the importance of HIV treatment adherence interventions at multiple levels both in and outside of the clinic, and providing more comprehensive training to providers to better serve PWH in adherence counseling, especially those who are most vulnerable..

Background Patient portals play an increasingly critical role in engaging patients in their health care. They have the potential to significantly impact the health of those living with chronic diseases, such as HIV, for whom consistent care engagement is both critical and complex. Objective The primary aim was to examine the longitudinal relationships between individual portal tool use and health-related outcomes in patients living with HIV. Design Retrospective cohort study using electronic health record data to examine the relationship between patient portal tool use and key HIV-specific, health-related outcomes in patients engaged in care in the Veterans Health Administration (VA) through the application of marginal structural models. Participants A national sample of patients living with HIV (PLWH) active in VA care who were registered to use the VA’s patient portal, My Health e Vet (MHV; n = 18,390) between 10/1/2012 and 4/1/2017. Main Measures The MHV tools examined were prescription refill (including prescription refill of an antiretroviral (ART) medication and any medication), secure messaging, view appointments, and view labs. Primary outcomes were viral load test receipt, viral load suppression, and ART medication adherence (measured as proportion of days covered). Key Results The use of prescription refill for any medication or for ART was positively associated with ART adherence. Secure messaging was positively associated with ART adherence but not with viral load test receipt or viral load suppression. The use of view appointments was positively associated with ART adherence and viral load test receipt but not viral load suppression. The use of view labs was positively associated with viral load suppression but not ART adherence or viral load test receipt. Conclusions These findings highlight the valuable role patient portals may play in improving health-related outcomes among PLWH and have implications for patients living with other types of chronic disease.

Introduction:The Veterans Health Administration (VHA) Diffusion of Excellence (DoE) program provides a system to identify, replicate, and spread promising practices across the largest integrated healthcare system in the United States. DoE identifies innovations that have been successfully implemented in the VHA through a Shark Tank style competition. VHA facility and regional directors bid resources needed to replicate promising practices. Winning facilities/regions receive external facilitation to aid in replication/implementation over the course of a year. DoE staff then support diffusion of successful practices across the nationwide VHA. Methods:Organized around the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) Framework, we summarize results of an ongoing long-term mixed-methods implementation evaluation of DoE. Data sources include: Shark Tank application and bid details, tracking practice adoptions through a Diffusion Marketplace, characteristics of VHA facilities, focus groups with Shark Tank bidders, structured observations of DoE events, surveys of DoE program participants, and semi-structured interviews of national VHA program office leaders, VHA healthcare system/facility executives, practice developers, implementation teams and facilitators. Results:In the first eight Shark Tanks (2016-2022), 3,280 Shark Tank applications were submitted; 88 were designated DoE Promising Practices (i.e., practices receive facilitated replication). DoE has effectively spread practices across the VHA, with 1,440 documented instances of adoption/replication of practices across the VHA. This includes 180 adoptions/replications in facilities located in rural areas. Leadership decisions to adopt innovations are often based on big picture considerations such as constituency support and linkage to organizational goals. DoE Promising Practices that have the greatest national spread have been successfully replicated at new sites during the facilitated replication process, have close partnerships with VHA national program offices, and tend to be less expensive to implement. Two indicators of sustainment indicate that 56 of the 88 Promising Practices are still being diffused across the VHA; 56% of facilities originally replicating the practices have sustained them, even up to 6 years after the first Shark Tank. Conclusion:DoE has developed a sustainable process for the identification, replication, and spread of promising practices as part of a learning health system committed to providing equitable access to high quality care.

BACKGROUND:Depression is the most diagnosed mental health condition among people living with HIV. Collaborative care is an effective intervention for depression, typically delivered in primary care settings. The HIV Translating Initiatives for Depression into Effective Solutions (HITIDES) clinical intervention involves a depression care team housed off-site that supports depression care delivery by HIV care providers. In a randomized controlled trial, HITIDES significantly improved depression symptoms for veterans living with HIV and delivered cost savings. However, no HIV clinics in the Veterans Health Administration (VHA) have implemented HITIDES; as such, it is unclear what implementation strategies are necessary to launch and sustain this intervention. METHODS:This hybrid type-3 effectiveness-implementation trial examines the implementation and effectiveness of HITIDES in 8 VHA HIV clinics randomly assigned to one of two implementation arms. Each arm uses a different implementation strategy package. Arm 1 includes an intervention operations guide; an on-site clinical champion who, with the help of a peer community of practice, will work with local clinicians and leadership to implement HITIDES at their site; and patient engagement in implementation tools. Arm 2 includes all strategies from Arm 1 with assistance from an external facilitator. The primary implementation outcomes is reach; secondary outcomes include adoption, implementation dose, depressive symptoms, and suicidal ideation. We will conduct a budget impact analysis of the implementation strategy packages. We hypothesize that Arm 2 will be associated with greater reach and adoption and that Arm 1 will be less costly. DISCUSSION:Preliminary work identified implementation strategies acceptable to veterans living with HIV and HIV care providers; however, the effectiveness and cost of these strategies are unknown. While the depression care team can deliver services consistently with high quality, the ability of the depression care team to engage with HIV care providers at sites is unknown. Findings from this study will be used to inform selection of implementation strategies for a broad rollout to enhance depression and suicide care for people living with HIV. TRIAL REGISTRATION:ClinicalTrials.gov ID: NCT05901272, Registered 10 May 2023, https://clinicaltrials.gov/study/NCT05901272.

Introduction The development and spread of innovation are known challenges in health care. The US Veterans Health Administration (VHA) created a "Shark Tank"-style competition directed at frontline employees. In this annual, systemwide competition, employees submit innovations to the competition, and winning innovations receive support for implementation in other facilities. Method A multiple case study design was used to understand facility engagement in the competition, and the relationship between engagement and organizational conditions. The authors created a typology to describe the relationship between facility engagement in the competition and organizational conditions for innovation. Results Overall, there was high participation in the VHA's competition across all 130 facilities. The authors identified 7 mutually exclusive types of facility engagement. Discussion As expected, facilities with the most established conditions for innovation were the most engaged in the competition. Additionally, other facilities had various ways to be involved. Consequently, there may be benefit to the VHA tailoring how they work with facilities, based on organizational conditions. Larger facilities with ongoing research and more resources may be more suited to develop innovations, whereas smaller facilities could benefit from a focus on adoption. Conclusion These insights are valuable to the VHA and can be used by other health care systems to tailor innovation programs and allocate resources based on diverse needs across a vast health care system.

BACKGROUND:Harm reduction strategies can decrease morbidity and mortality associated with substance use. Various barriers limit conversation around substance use between clinicians and patients. Graphic medicine techniques can inform and encourage patient-centered conversations about substance use. We describe the co-development of a harm reduction-focused graphic medicine comic that depicts the infectious risks associated with injection drug use and patient-centered approaches to providing education about potential risk mitigation strategies. METHODS:We formed a co-design group of veterans with lived experience with substance use, physicians, health services researchers, and community-based harm reduction leaders. Over the course of ten sessions, the co-design team developed a storyline and key messages, reviewed draft content and worked with a graphic designer to develop a comic incorporating the veterans' input. During each session, co-design leads presented drafts of the comic and invited feedback from the group. The comic was edited and adapted via this iterative process. RESULTS:The comic depicts a fictionalized clinical vignette in which a patient develops an injection-related abscess and presents to their primary care provider. The dialogue highlights key healthcare principles, including patient autonomy and agency, and highlights strategies for safer use, rather than emphasizing abstinence. Feedback from co-design group participants highlights lessons learned during the development process. DISCUSSION:Graphic medicine is ideally suited for a patient-centered curriculum about harm reduction. This project is one of several interventions that will be integrated into VA facilities nationally to support incorporation of harm reduction principles into the care of persons who inject drugs.

Abstract The US Department of Veteran Affairs (VA) is implementing a patient-centered, “Whole Health System of Care” to align care with What Matters Most to patients within their unique circumstances. Implementation is focused on primary care, where most patients receive care. Yet HIV Clinics have historically provided both HIV and primary care because of the complexity of HIV. People living with HIV are now aging and experiencing a constellation of health and life circumstances that would benefit from a Whole Health approach. While there is desire to spread Whole Health beyond primary care, little is known about how to integrate Whole Health into HIV Clinics. We sought to identify Whole Health implementation considerations for HIV Clinics. Our qualitative study design included interviews with vignettes based on our prior work, illustrating themes like aging alone. Findings were mapped to the i-PARIHS implementation framework which includes recipients (HIV providers), context (HIV clinics), and innovation (Whole Health). We interviewed physicians, psychologists, nurses and leadership (N=11) from three HIV Clinics (Northeast, Northwest, South). Participants were largely aware of Whole Health, although few had taken trainings and no clinics currently offered Whole Health services. Many expressed interest incorporating Whole Health into HIV care. They also saw great value, given patients’ complexities. Participants described logistical barriers hindering implementation, like awareness of specific resources or how to refer. Only some providers were able to conceptualize a Whole Health clinical encounter- where patients’ life circumstances are connected to health. HIV Clinics offer an ideal setting to spread Whole Health.

Background Since 2015, the Veterans Health Administration (VHA) Diffusion of Excellence Program has supported spread of practices developed by frontline employees. Shark Tank-style competitions encourage "Sharks" nationwide (VHA medical center/regional directors) to bid for the opportunity to implement practices at their institutions. Methods The authors evaluated bidding strategies (2016-2020), developing the "QuickView" practice comparator to promote informed bidding. Program leaders distributed QuickView and revised versions in subsequent competitions. Our team utilized in-person observation, online chats after the competition, bidder interviews, and bid analysis to evaluate QuickView use. Bids were ranked based on demonstrated understanding of resources required for practice implementation. Results Sharks stated that QuickView supported preparation before the competition and suggested improvements. Our revised tool reported necessary staff time and incorporated a "WishList" from practice finalists detailing minimum requirements for successful implementation. Bids from later years reflected increased review of facilities' current states before the competition and increased understanding of the resources needed for implementation. Percentage of bids describing local need for the practice rose from 2016 to 2020: 4.7% (6/127); 62.1% (54/87); 78.3% (36/46); 80.6% (29/36); 89.7% (26/29). Percentage of bids committing specific resources rose following QuickView introduction: 81.1% (103/127) in 2016, 69.0% (60/87) in 2017, then 73.9% (34/46) in 2018, 88.9% (32/36) in 2019, and 89.7% (26/29) in 2020. Discussion In the years following QuickView/WishList implementation, bids reflected increased assessment before the competition of both local needs and available resources. Conclusion Selection of a new practice for implementation requires an understanding of local need, necessary resources, and fit. QuickView and WishList appear to support these determinations.