Utilization of the Veterans Affairs' Transgender E-consultation Program by Health Care Providers: Mixed-Methods Study

John R Blosnich; Keri L Rodriguez; Kristina L Hruska; Dio Kavalieratos; Adam J Gordon; Alexis Matza; Susan M Mejia; Jillian C Shipherd; Michael R Kauth

doi:10.2196/11695

Utilization of the Veterans Affairs' Transgender E-consultation Program by Health Care Providers: Mixed-Methods Study

JMIR Med Inform. 2019 Jan 14;7(1):e11695. doi: 10.2196/11695.

Authors

John R Blosnich^#^{1

2}, Keri L Rodriguez^#^{1

2}, Kristina L Hruska^#¹, Dio Kavalieratos^#^{1

2}, Adam J Gordon^{3

4}, Alexis Matza^#⁵, Susan M Mejia^#^{5

6}, Jillian C Shipherd^#^{5

7

8}, Michael R Kauth^#^{5

6

9}

Affiliations

¹ Center for Health Equity Research and Promotion, Department of Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, United States.
² Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States.
³ Informatics, Decision-Enhancement, and Analytic Sciences Center, Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, United States.
⁴ Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, UT, United States.
⁵ Lesbian, Gay, Bisexual, and Transgender Health Program, Office of Patient Care Services, Veterans Health Administration, Washington, DC, United States.
⁶ South Central Mental Illness Research, Education and Clinical Center, Michael E DeBakey Veterans Affairs Medical Center, Houston, TX, United States.
⁷ National Center for Posttraumatic Stress Disorder, Department of Veterans Affairs Boston Healthcare System, Boston, MA, United States.
⁸ Boston University School of Medicine, Boston, MA, United States.
⁹ Department of Psychiatry, Baylor College of Medicine, Houston, TX, United States.

^# Contributed equally.

PMID: 31344672
PMCID: PMC6682290
DOI: 10.2196/11695

Abstract

Background: In 2015, the Department of Veterans Affairs (VA) nationally implemented a transgender e-consultation (e-consult) program with expert clinical guidance for providers.

Objective: This mixed-methods project aimed to describe providers' program experiences, reasons for nonuse of the program, and ways to improve the program use.

Methods: From January to May 2017, 15 urban and rural VA providers who submitted at least one e-consult in the last year participated in semistructured interviews about their program experiences, which were analyzed using content analysis. From November to December 2017, 53 providers who encountered transgender patients but did not utilize the program participated in a brief online survey on the reasons for nonuse of the program and the facilitators encouraging use.

Results: Qualitative analysis showed that providers learned of the program through email; colleagues; the electronic health record (EHR) system; and participation in the VA Lesbian, Gay, Bisexual, and Transgender committees or educational trainings. Providers used the program to establish care plans, hormone therapy recommendations, sexual and reproductive health education, surgical treatment education, patient-provider communication guidance, and second opinions. The facilitators of program use included understandable recommendations, ease of use through the EHR system, and status as the only transgender resource for rural providers. Barriers to use included time constraints, communication-related problems with the e-consult, impractical recommendations for underresourced sites, and misunderstanding of the e-consult purpose. Suggestions for improvement included addition of concise or sectioned responses, expansion of program awareness among providers or patients, designation of a follow-up contact person, and increase in provider education about transgender veterans and related care. Quantitative analysis showed that the common reasons for nonuse of the program were no knowledge of the program (54%), no need of the program (32%), and receipt of help from a colleague outside of e-consult (24%). Common suggestions to improve the program use in quantitative analyses included provision of more information about where to find e-consult in the chart, guidance on talking with patients about the program, and e-mail announcements to improve provider awareness of the program. Post hoc exploratory analyses showed no differences between urban and rural providers.

Conclusions: The VA transgender e-consult program is useful for providers, but there are several barriers to implementing recommendations, some of which are especially challenging for rural providers. Addressing the identified barriers and enhancing the facilitators may improve program use and quality care for transgender veterans.

Keywords: teleconsultation; telemedicine; transgender persons; veteran health; veterans.

©John R Blosnich, Keri L Rodriguez, Kristina L Hruska, Dio Kavalieratos, Adam J Gordon, Alexis Matza, Susan M Mejia, Jillian C Shipherd, Michael R Kauth. Originally published in JMIR Medical Informatics (http://medinform.jmir.org), 14.01.2019.