JMIR Publications

ABSTRACT

Background:

Patients with multimorbidity have complex healthcare needs and are at high-risk for adverse health outcomes. Primary care teams need tools to effectively and proactively plan care for these patients. We developed VET-PATHS (VETeran PAnel management Tool for High-risk Subgroups), a novel care planning informatics tool for complex primary care patients. VET-PATHS a) groups patients by chronic condition profile via latent class analysis of electronic health record (EHR) data, then b) jumpstarts care planning by suggesting ‘care steps’ based on data-driven high-priority care for the group, indicated as not receive by EHR.

Objective:

Iteratively adapt VET-PATHS with user input, then test feasibility and acceptability of tool use by frontline primary care teams for their empaneled high-risk patients.

Methods:

Three rounds of user-centered design sessions with 17 primary care providers and registered nurses were held at 5 sites from 2019-2021, for feedback on VET-PATHS layout, content, and user-interface. Feedback was summarized into 4 user experience domains (useful, desirable, credible, and usable), leading to progressively updated prototypes. After national tool release, we conducted a pilot intervention study in 2023-2024 with 6 primary care teams at 4 sites. Teams used VET-PATHS during asynchronous regular meetings. Tool use and resulting care plans were assessed by templated observation during meetings and post-pilot chart review. Individual qualitative interviews were analyzed by rapid template analysis for themes of feasibility, acceptability, and utility.

Results:

User-centered feedback led to updates in tool content, context (e.g., use in proactive panel management), targeting of users (e.g., focusing on primary care providers as the principal users), and layout of informational displays. Pilot intervention teams used VET-PATHS over 4-8 weekly team meetings (mean length, 24 min (range 16-49m)), in which they actively reviewed 80% (280/351) of empaneled high-risk patients visible in the tool. Tool use prompted teams to plan 127 new actions for 91 unique patients (33% of patients reviewed), and document >1 new care plans for 19% of patients reviewed. Common actions included requests to return to clinic (27%), referrals (20%), or vaccinations (19%). Of actions planned, 53 (42%) were received by patients. Four teams with general patient panels (n=11 interviews) described higher acceptability. Two ‘focused’ teams with smaller more homogenous patient panels, e.g. substance use disorder, (n=3 interviews) found care steps less useful. Teams described how VET-PATHS improved efficiency of care planning through automated patient grouping and identification of care gaps, and increased multidisciplinary role involvement.

Conclusions:

User-centered improvements to VET-PATHS were designed to help clinicians process and use complex information about patient multimorbidity to efficiently create new care plans. In subsequent production, VET-PATHS was acceptable and feasible to use by frontline primary care teams, particularly with larger, more heterogenous patient panels, and led to concrete changes to clinical care delivery. Clinical Trial: N/A