Objectives:Electronic health record (EHR) order preference lists and order sets potentially improve efficiency but have limited utility in complex primary care settings. We assessed adoption, impact on ordering efficiency, and clinician perceptions of a comprehensive set of nested order panels (xOrders) for adult primary care. Methods:In Phase 1 (gradual implementation), 404 xOrders were released (November 29, 2020-September 25, 2021). Beginning of Phase 2 (rapid implementation), 630 xOrders were released with an additional 253 xOrders added (September 26, 2021-June 24, 2023). Three outcomes captured adoption: xOrders used per week; number of clinician users per week; and percent of xOrders of all orders. Impact of xOrders on times in orders per encounter per clinician was evaluated with mixed effects interrupted time series. t-Tests evaluated differences between low, moderate, and high utilizers. A survey captured clinicians' perceptions in November 2022. Results:xOrders were used 536 (SD, 245) times/week and by 57(15) clinicians/week in Phase 2. xOrders as a percent of all orders ranged from 0% to 31% across clinicians. Time spent in orders per encounter decreased by 14 ± 5 s (P =.01) from Phase 1 to 2 for high utilizers, decreased by 7(3) s (P=.05) for moderate utilizers, and increased by 1(3) s for low utilizers (P=.81); low and high utilizers were significantly different (P=.02). Most (77%) survey respondents agreed that xOrders improved ordering efficiency. Discussion and Conclusions:Despite yielding time savings and positive clinician feedback, the xOrder intervention showed limited adoption and impact, suggesting the need for expanded content and increased adoption to realize larger efficiency gains.

Redundant and time-consuming paperwork is considered by patients to be a form of low-value care. The implementation of new digital health technologies, such as electronic medical history forms, continues to increase in healthcare settings to replace paper forms. However, implementation is often not as simple as merely installing new technology; de-implementation of pre-existing practices or artifacts may be needed for successful integration. Understand factors that promoted or inhibited de-implementing paper-based medical history forms within a complex academic healthcare setting through the lens of Normalization Process Theory (NPT). Observations of 10 community and faculty clinics utilizing rapid ethnography approaches with NPT as a guiding framework. A total of 106 staff (medical assistants, patient care coordinators, front desk staff), managers, and physicians/nurses were interviewed during 10 site visits. Paper-based history questionnaires continued to exist in many settings, either retained as “backups” or reintroduced without management’s knowledge. Four findings related to the success of de-implementation mapped onto all four constructs of NPT: 1) De-implementation benefits from clearly communicating how patients will benefit (coherence); 2) De-implementation benefits from a holistic, team-based perspective (cognitive participation); 3) De-implementation requires attentive training and resources to build new habits (collective action); and 4) Sustaining de-implementation benefits from on-site observation (reflexive monitoring). These findings highlight both how implementation and de-implementation work can go hand-in-hand, but also in how de-implementation can have unique factors and outcomes that may necessitate distinct strategies: ensuring that all staff understand the ways in which patients will benefit and are equipped to communicate the change to their patients, and utilizing observational methods to monitor, audit, or evaluate de-implementation.

BACKGROUND: Despite the need to increase access to palliative care for aging populations, there is limited research on effective strategies for palliative care service implementation. Identifying implementation strategies that support the integration of services in different clinical settings is a necessary step for the efficient deployment of resources to improve outcomes. This study explores the implementation strategies used by six diverse California health systems to expand palliative care services, and the relationship between strategies and implementation outcomes and reach. METHODS: A longitudinal mixed methods study utilizing document review, key informant interviews, and program data to assess implementation and effectiveness was conducted using a convergent parallel design. A deductive content analysis and matrix analysis using the Expert Recommendations for Implementing Change (ERIC) framework to identify and compare strategies across sites was completed, along with a thematic analysis of the relationship between strategies and reach, feasibility, acceptability, adoption, and sustainability. RESULTS: In total, 33 of the 73 discrete ERIC strategies were identified, spanning all nine strategy domains. Sites used between 11 and 23 implementation strategies for expanding palliative care programs. All six sites utilized financial strategies, evaluative and iterative strategies, supported clinicians, developed stakeholder interrelationships, and trained and educated stakeholders. We identified four themes that supported outcomes: (1) establishing and sustaining a trained workforce, particularly creating new clinical teams with physician leadership made service provision feasible and fostered acceptance and adoption; (2) identifying cases was important for referrals; (3) engaging providers through relationship development and education was crucial for acceptability, adoption and sustainability; and (4) involving organizational leadership, specifically active and enduring executive sponsorship, aided feasibility and sustainability. CONCLUSIONS: Implementation strategies for expanding palliative care services focused on building a presence by establishing a trained workforce to provide the service, identifying cases and engaging providers to increase and sustain acceptability and adoption, involving organizational leadership for feasibility and sustainment, and securing financial support to feasibly launch the service. This study compares how different implementation strategies were used in different settings, and the impact. Palliative care programs looking to expand services should focus on these core strategies to maximize efforts, and reach more patients.

Introduction:Learning collaboratives are frequently used within healthcare to facilitate practice improvement through collaboration among clinical teams across multiple organizations. The aim of this study was to use the Agency for Healthcare Research and Quality (AHRQ) collaborative taxonomy to identify collaborative elements that influence successful implementation of clinical practices and sustain improvements in four radiology learning collaboratives. Methods:We used an ethnographic approach to evaluate a learning collaborative network using the AHRQ collaborative taxonomy. Data collection included observations, interviews, and review of site performance metrics. Results:We identified four themes that spanned the four AHRQ taxonomy primary elements (innovation, time, communication, social system) that explained the influence of the collaborative structure on site improvements and sustained success: (1) structured education in quality improvement and access to quality improvement tools provides a framework for quality improvement; (2) an expert-guided, structured improvement process sets the pace of improvement; (3) intentional participant interaction and contribution in meetings reinforces accountability; and (4) credible leadership and facilitation sustains participation. Conclusions:While we identified all four primary elements of the AHRQ framework as important for a successful learning collaborative, social system elements were particularly dominant in their influence on sites' success. In particular, expert, credible leaders who provided the right tools, at the right time and pace, with constructive guidance were critical for maintaining site engagement and driving problem-solving.

We aim to incorporate physician insights into the development of a performance dashboard based on a novel patient experience survey system at a large academic health system. A multidisciplinary team of physicians, researchers, and designers met regularly to develop the dashboard informed by Clinical Performance Feedback Intervention Theory. Semistructured qualitative interviews with frontline physicians underwent combined inductive-deductive thematic analysis to inform dashboard improvements. A total of 20 interviews were conducted April-July 2023 with 9 neurologists and 6 primary care physicians in 2 phases. Physician preferences converged along design, content, and administration features, which were incorporated into the dashboard and accepted by physicians during phase 2. Important themes included establishment of survey credibility, preference for qualitative over quantitative data, and associated incentive structure. Dashboard design required an intuitive data overview with features such as hover-over insights that allowed deeper exploration. Physicians valued patient comments over quantitative data, prompting further redesign of the dashboard to prioritize qualitative insights, contrasting with the national emphasis on quantitative benchmarks.

AbstractIntroductionStanford Medicine is working to better coordinate care across the Stanford healthcare system, as well as improve patient and provider experiences in seeking and receiving care. This study aimed to explore the complexities of moving from a fragmented to an integrated academic healthcare system and to identify and explain factors (e.g., facilitators and barriers) of the implementation of three interventions meant to improve patient experience, reduce staff burden, and integrate health care systems across faculty and community settings.MethodsWe conducted qualitative semi‐structured interviews via Zoom with faculty and community physicians. Interviews were audio‐recorded, professionally transcribed, and analyzed using the Consolidated Framework for Implementation Research (CFIR) and open coding. Using consensus coding approaches, researchers met regularly to discuss themes and adaptations to CFIR.ResultsWe analyzed transcripts from interviews with physicians (n = 26). Factors impacting integration included the following: (1) physicians supported the interventions, promoting mission alignment; (2) physicians were motivated for change, reporting the existing system was intolerable; (3) physicians reported different priorities between clinics: faculty versus community and primary care versus specialty; (4) physicians prioritized interpersonal versus system solutions; (5) specialists were wary of unintended consequences of integration, specifically inappropriate bookings or patients being redirected to other clinics. Broadly speaking, facilitator factors 1–2 focused on the openness to, and tension for, change; and barrier factors 3–5 promoted or sustained variation across specialties and faculty/community clinics.ConclusionsOur results illustrate the challenges and opportunities of moving from a fragmented to an integrated healthcare system and emphasize the importance of building shared culture, collaboration, and coordinated actions across and within an integrated healthcare network.

Importance:Leveraging technology to prompt team-based care might improve ambulatory hypertension care. Objective:To assess whether an electronic medical record (EMR) high blood pressure (BP) advisory improves hypertension control. Design, Setting, and Participants:This quality improvement study assessed hypertension control in patients presenting to primary care office visits from March 2018 to February 2020. Data were included from 28 primary care clinics (8 clinics contributed data toward the primary objective and 28 contributed data toward secondary objectives) in a single academic health system in California before and after intervention and concurrent care team observations and interviews assessing implementation. Data were analyzed from November 2019 to October 2020. Intervention:An EMR high BP advisory combined with team training, audit, and feedback. EMR entry of elevated BP (systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg) prompted an interruptive medical assistant-facing advisory to recheck BP. Persistently elevated BP prompted a second interruptive clinician-facing advisory with order panel link. Main Outcomes and Measures:The primary outcome was BP lower than 140 mm Hg systolic and lower than 90 mm Hg diastolic during an office visit within 6 months of an initial primary care visit. Secondary outcomes included BP recheck after initial elevated value, antihypertensive medication change, and new hypertension diagnoses. Qualitative outcomes focused on implementation barriers and facilitators. Results:The primary outcome assessed 2760 control patients and 3018 intervention patients with preexisting hypertension (mean [SD] age, 66.5 [14.4] years; 2847 [49.2%] women, 1746 [30.2%] Asian, 619 [10.7%] Hispanic, and 2407 [41.7%] White). The likelihood of hypertension control increased 18.3% per month on average (odds ratio [OR], 1.18; 95% CI, 1.10-1.27; P < .001) in the intervention vs control groups. Modeled rates of adjusted hypertension control over 6 months increased from 82.3% to 92.3% for the intervention cohort and decreased from 71.5% to 70.3% for the control (preintervention) cohort. BP recheck rate increased (from 37.6% to 77.9%; OR, 4.76; 95% CI, 4.45-5.10; P < .001), while ordered antihypertensive medications was unchanged. New hypertension diagnosis increased from 12.1% to 20.6% (OR, 1.34; 95% CI, 1.13-1.58; P = .01). In interviews of 34 care team members (clinicians, medical assistants, and managers) from 6 clinics, implementation barriers included competing priorities and time for BP rechecks, order panel complexity, and mixed clinician engagement; facilitators included intervention visibility, EMR integration, and team-based approach. Conclusions and Relevance:This quality improvement study of an EMR high BP advisory intervention found significantly improved primary care hypertension control and diagnosis due to the combination of team-based care and technology.

Background: The Serious Illness Conversation Guide was developed to support high quality goals of care conversations with seriously ill patients; however, guide implementation for patients with limited English proficiency (LEP) has not been studied. This evaluation aimed to explore serious illness conversations with hospitalized LEP patients, defined as those with a non-English language documented, from clinician and interpreter perspectives; and assess differences in documentation in the electronic medical record (EMR) as a quality improvement effort. Methods: Parallel mixed methods evaluation including thematic analysis of observations and interviews with medical interpreters (n = 14), occupational therapists (n = 9), registered dietitians (n = 6), and resident physicians (n = 3) of a quaternary academic hospital in the United States. Comparison of EMR documentation for hospital admissions with English proficient (N = 7396) and LEP patients (N = 2326). Results: Six themes characterized serious illness communication and guide use with LEP patients. As compared to other clinical encounters, both interpreters and clinicians perceived serious illness communication as unique. Both groups acknowledged that interpreters convey meaning, though being an effective voice of the clinician required advanced preparation of the interpreter, even when the guide was used. There were no differences in documentation between the groups (4.7% (345/7396) versus 5.4% (126/2326); p = 0.21). Conclusions: Even when the guide is used, there may be differences in serious illness communication quality with LEP patients depending on how clinicians engage with the guide and interpreter preparation. The guide may be a method to enhance communication quality, but for LEP patients, requires the parallel implementation of workflows that support high-quality communication.

Electronic health record (EHR) usage measures may quantify physician activity at scale and predict practice settings with a high risk for physician burnout, but their relation to experiences is poorly understood.This study aimed to explore the EHR-related experiences and well-being of primary care physicians in comparison to EHR usage measures identified as important for predicting burnout from a machine learning model.Exploratory qualitative study with semi-structured interviews of primary care physicians and clinic managers from a large academic health system and its community physician partners. We included primary care clinics with high burnout scores, low burnout scores, or large changes in burnout scores between 2020 and 2022, relative to all primary care clinics in the health system. We conducted inductive and deductive coding of interview responses using a priori themes related to the machine learning model categories of patient load, documentation burden, messaging burden, orders, and physician distress and fulfillment.Interviews with 16 physicians and 4 clinic managers identified burdens related to three dominant themes: (1) messaging and documentation burdens are high and require more time than most physicians have available during standard working hours. (2) While EHR-related burdens are high they also provide patient-care benefits. (3) Turnover and insufficient staffing exacerbate time demands associated with patient load. Dimensions that are difficult to quantify, such as a perceived imbalance between job demands and individual resources, also contribute to burnout and were consistent across all themes.EHR-related work burden, largely quantifiable through EHR usage measures, are major source of distress among primary care physicians. Organizational recognition of this work as well as staffing and support to predict associated work burden may increase professional fulfillment and reduce burnout among primary care physicians.

BACKGROUND: A limited transthoracic echocardiogram (TTE) can be an appropriate, lower-cost substitute for a full TTE. We assessed the impact of an electronic health record alternative alert promoting the adoption of limited TTEs on the ordering practices of cardiology clinicians and primary care providers and captured their perspectives on the initiative. METHODS: The alert was deployed in a cardiology clinic and 4 primary care clinics at an academic medical center. The alert provided clinical guidance on the appropriate use of limited TTEs when a clinician selected a full TTE order. We used logistic regression to estimate the change in the proportion of limited versus full TTEs ordered between the baseline and intervention periods in clinics with and without the alert. We also conducted interviews with 24 clinicians (5 cardiologists and 19 primary care providers) to identify implementation barriers and facilitators. RESULTS: Cardiology clinicians ordered 10 654 and 3761 TTEs during the baseline and intervention periods, respectively, for 9100 patients. Primary care providers ordered 723 and 617 TTEs during the baseline and intervention periods for 1273 patients. The model estimated that the percentage of limited TTEs ordered increased by 16.1 +/- 2.3 percentage points (P<0.0001) in the cardiology clinic with the alert and by 13.2 +/- 1.5 percentage points (P<0.0001) in the primary care clinics with the alert from baseline to post-intervention. Ordering practices did not change in the cardiology (0.7 +/- 0.6 percentage points; P=0.24) or primary care (0.7 +/- 1.0 percentage points; P=0.52) clinics without the alert. Clinicians viewed the alert as acceptable. Cardiologists appreciated that the alert was concise, whereas primary care providers wanted more information from the alert. CONCLUSIONS: An alternative alert providing clinical guidance on the use of limited TTEs at the point of care increased the selection of this lower-cost test in cardiology and primary care clinics. Perspectives on the alert differed between specialists and nonspecialists, highlighting the importance of tailoring intervention design to clinical expertise.

Background Treatment and control of hypertension remains suboptimal, and health systems are increasingly trying to address hypertension with strategies combining multiple interventions. Objective The purpose of this pilot study was to examine implementation outcomes and an effectiveness outcome of BP control for a quality improvement project focused on multifaceted hypertension intervention. Design, Setting, and Participants: The project was implemented at a single primary care clinic within an academic medical center. Components of the multifaceted intervention included clinical team capacity-building and a longitudinal telehealth health coaching delivered by medical assistants (MAs) and a clinical pharmacist. Approach: We assessed Proctor’s implementation outcomes of adoption, acceptability, fidelity, and feasibility and sustainability. Quantitative data included process participation and self-reported BP readings. Qualitative data originated from interviews and debriefing sessions with clinical team members. Key Results: There was a difference between the mean pre-intervention and post-intervention systolic BP (p = 0.01,n = 13). Our implementation results showed mixed adoption and acceptability. Outreach to 236 patients required to achieve goal enrollment of 30, and of those just 16 participated in health coaching. Acceptability was limited by MA stress and technology barriers. Fidelity was supported by the structured health education session, and health coaching tools and training. Feasible and potential sustainability was achieved with some barriers, primarily related to the need for additional MA training, time and resources. Opportunities exist to further promote MA engagement and training through peer learning initiatives that may also positively impact self-efficacy and empowerment. Conclusions We found a novel telehealth hypertension management pilot improved hypertension care – with minimal expanded clinic resources and no impact on primary care physician access. Redesigning care delivery to extend the primary care team to include non-physician staff such as MAs with remote patient monitoring for blood pressure and seamless integration of technology and human-components of complex interventions, can help inform future team-based care initiatives for hypertension.

OBJECTIVES:Patient mindsets influence health outcomes; yet trainings focused on care teams' understanding, recognizing, and shaping patient mindsets do not exist. This paper aims to describe and evaluate initial reception of the "Medicine Plus Mindset" training program. METHODS:Clinicians and staff at five primary care clinics (N = 186) in the San Francisco Bay Area received the Medicine Plus Mindset Training. The Medicine Plus Mindset training consists of a two-hour training program plus a one-hour follow-up session including: (a) evidence to help care teams understand patients' mindsets' influence on treatment; (b) a framework to support care teams in identifying specific patient mindsets; and (c) strategies to shape patient mindsets. RESULTS:We used a common model (Kirkpatrick) to evaluate the training based on participants' reaction, learnings, and behavior. Reaction: Participants rated the training as highly useful and enjoyable. Learnings: The training increased the perceived importance of mindsets in healthcare and improved self-reported efficacy of using mindsets in practice. Behavior: The training increased reported frequency of shaping patient mindsets. CONCLUSIONS:Development of this training and the study's results introduce a promising and feasible approach for integrating mindset into clinical practice. Practice Implications Mindset training can add a valuable dimension to clinical care and should be integrated into training and clinical practice.

Abstract Background COVID-19 impacted the mental health of healthcare workers, who endured pressures as they provided care during a prolonged crisis. We aimed to explore whether and how a Trauma-Informed Care (TIC) approach was reflected in qualitative perspectives from healthcare leaders of their experience during COVID-19 (2020–2021). Methods Semi-structured interviews with healthcare leaders from four institutions were conducted. Data analysis consisted of four stages informed by interpretative phenomenological analysis: 1) deductive coding using TIC assumptions, 2) inductive thematic analysis of coded excerpts, 3) keyword-in-context coding of full transcripts for 6 TIC principles with integration into prior inductive themes, and 4) interpretation of themes through 6 TIC principles (safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice, and choice; and awareness of cultural, historical, and gender issues). Results The actions of leaders (n = 28) that were reported as successful and supportive responses to the COVID-19 pandemic or else missed opportunities reflected core principles of Trauma-Informed Care. To promote safety, leaders reported affirmative efforts to protect staff by providing appropriate physical protection, and enhanced psychological safety by providing channels for communication about emotional well-being. To promote trustworthiness and transparency, leaders listened to their staff, shared current COVID-19 information, and increased frequency of meetings to disseminate accurate information. To promote mutual support, strategies included wellness check-ins, sharing uplifting stories, affirming common goals, articulating fears, and leading by example. Examples of empowerment included: making time and adjusting modalities for flexible communication; naming challenges outside of the hospital; and functioning as a channel for complaints. Reported missed opportunities included needing more dedicated time and space for healthcare employees to process emotions, failures in leadership managing their own anxiety, and needing better support for middle managers. Awareness of the TIC principle of cultural, historical, and gender issues was largely absent. Results informed the nascent Trauma-Informed Healthcare Leadership (TIHL) framework. Conclusions We propose the Trauma-Informed Healthcare Leadership framework as a useful schema for action and analysis. This approach yields recommendations for healthcare leaders including creating designated spaces for emotional processing, and establishing consistent check-ins that reference personal and professional well-being.

OBJECTIVES:Exercise stress echocardiograms (stress echos) are overused, whereas exercise stress electrocardiograms (stress ECGs) can be an appropriate, lower-cost substitute. In this post hoc, mixed methods evaluation, we assessed an initiative promoting value-based, guideline-concordant ordering practices in primary care (PC) and cardiology clinics.METHODS:Change in percent of stress ECGs ordered of all exercise stress tests (stress ECGs and echos) was calculated between three periods: baseline (January 2019-February 2020); Period 1 with reduced stress ECG report turnaround time + PC-targeted education (began June 2020); and Period 2 with the addition of electronic health record-based alternative alert (AA) providing point-of-care clinical decision support. The AA was deployed in two of five PC clinics in July 2020, two additional PC clinics in January 2021, and one of four cardiology clinics in February 2021. Nineteen primary care providers (PCPs) and five cardiologists were interviewed in Period 2.RESULTS:Clinicians reported reducing ECG report turnaround time was crucial for adoption. PCPs specifically reported that value-based education helped change their practice. In PC, the percent of stress ECGs ordered increased by 38% ± 6% (SE) (p < 0.0001) from baseline to Period 1. Most PCPs identified the AA as the most impactful initiative, yet stress ECG ordering did not change (6% ± 6%; p = 0.34) between Periods 1 and 2. In contrast, cardiologists reportedly relied on their expertise rather than AAs, yet their stress ECGs orders increased from Period 1 to 2 to a larger degree in the cardiology clinic with the AA (12% ± 5%; p = 0.01) than clinics without the AA (6% ± 2%; p = 0.01). The percent of stress ECGs ordered was higher in Period 2 than baseline for both specialties (both p < 0.0001).CONCLUSIONS:This initiative influenced ordering behaviour in PC and cardiology clinics. However, clinicians' perceptions of the initiative varied between specialties and did not always align with the observed behaviour change.

Introduction: Little is known about which conditions seen in primary care are appropriate for video visits. This study evaluated video visits compared to office visits for six conditions: abdominal pain, joint pain, back pain, headache, chest pain, and dizziness. Methods: Six hundred charts of adult patients from our institution's same-day outpatient clinic were reviewed in this study. Charts for video visits evaluating the aforementioned chief complaints that occurred between August and October 2020 were reviewed and compared with charts for office visits that occurred from August to September 2019. Frequencies of 3-week follow-up visits, Emergency Room visits, imaging, and referrals for office and video visits were measured. Reasons for in-person evaluation for patients seen by video were determined by review of clinician notes. Results: Three-week in-person follow-up was more frequent for patients presenting with chest pain (52% vs 18%, p= 0.0007) and joint pain (24% vs 8%, p= 0.05) after video evaluation, relative to an office evaluation. Three-week in-person follow-up was also more frequent for patients presenting with dizziness (38% vs 28%) and low back pain (24% vs 14%); however, this difference was not statistically significant. Patients presenting with headache and abdominal pain did not have a higher rate of follow-up. Discussion: Based on the frequency of in-person follow-up, this study suggests that video visits are generally adequate for evaluating headache and abdominal pain. Patients with dizziness and chest pain have the highest frequency of in-person and Emergency Room follow-up within 3 weeks when first seen by video compared to other conditions evaluated and may be less suitable for an initial video visit. Institutions can consider these findings when scheduling and providing guidance to patients on what type of visit is most appropriate for their symptoms.

BackgroundInnovative solutions to nursing care are needed to address nurse, health system, patient, and caregiver concerns related to nursing wellness, work flexibility and control, workforce retention and pipeline, and access to patient care. One innovative approach includes a novel health care delivery model enabling nurse-led, off-hours wound care (PocketRN) to triage emergent concerns and provide additional patient health education via telehealth. ObjectiveThis pilot study aimed to evaluate the implementation of PocketRN from the perspective of nurses and patients. MethodsPatients and part-time or per-diem, wound care–certified and generalist nurses were recruited through the Stanford Medicine Advanced Wound Care Center in 2021 and 2022. Qualitative data included semistructured interviews with nurses and patients and clinical documentation review. Quantitative data included app use and brief end-of-interaction in-app satisfaction surveys. ResultsThis pilot study suggests that an app-based nursing care delivery model is acceptable, clinically appropriate, and feasible. Low technology literacy had a modest effect on initial patient adoption; this barrier was addressed with built-in outreach and by simplifying the patient experience (eg, via phone instead of video calls). This approach was acceptable for users, despite total patient enrollment and use numbers being lower than anticipated (N=49; 17/49, 35% of patients used the app at least once beyond the orientation call). We interviewed 10 patients: 7 who had used the app were satisfied with it and reported that real-time advice after hours reduced anxiety, and 3 who had not used the app after enrollment reported having other resources for health care advice and noted their perception that this tool was meant for urgent issues, which did not occur for them. Interviewed nurses (n=10) appreciated working from home, and they reported comfort with the scope of practice and added quality of care facilitated by video capabilities; there was interest in additional wound care–specific training for nonspecialized nurses. Nurses were able to provide direct patient care over the web, including the few participating nurses who were unable to perform in-person care (n=2). ConclusionsThis evaluation provides insights into the integration of technology into standard health care services, such as in-clinic wound care. Using in-system nurses with access to electronic medical records and specialized knowledge facilitated app integration and continuity of care. This care delivery model satisfied nurse desires for flexible and remote work and reduced patient anxiety, potentially reducing postoperative wound care complications. Feasibility was negatively impacted by patients’ technology literacy and few language options; additional patient training, education, and language support are needed to support equitable access. Adoption was impacted by a lack of perceived need for additional care; lower-touch or higher-acuity settings with a longer wait between visits could be a better fit for this type of nurse-led care.