Blosnich John R, Rodriguez Keri L, Hruska Kristina L, Kavalieratos Dio, Gordon Adam J, Matza Alexis, Mejia Susan M, Shipherd Jillian C, Kauth Michael R
Center for Health Equity Research and Promotion, Department of Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, United States.
Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States.
JMIR Med Inform. 2019 Jan 14;7(1):e11695. doi: 10.2196/11695.
In 2015, the Department of Veterans Affairs (VA) nationally implemented a transgender e-consultation (e-consult) program with expert clinical guidance for providers.
This mixed-methods project aimed to describe providers' program experiences, reasons for nonuse of the program, and ways to improve the program use.
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.
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.
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.
2015年，美国退伍军人事务部（VA）在全国范围内实施了一项跨性别者电子咨询（e-consult）计划，为医疗服务提供者提供专家临床指导。
这个混合方法项目旨在描述医疗服务提供者对该计划的体验、不使用该计划的原因以及改善计划使用情况的方法。
2017年1月至5月，15名在过去一年中至少提交过一次电子咨询的城乡VA医疗服务提供者参与了关于他们对该计划体验的半结构化访谈，并使用内容分析法进行分析。2017年11月至12月，53名遇到过跨性别患者但未使用该计划的医疗服务提供者参与了一项关于不使用该计划的原因和鼓励使用的促进因素的简短在线调查。
定性分析表明，医疗服务提供者通过电子邮件、同事、电子健康记录（EHR）系统以及参与VA女同性恋、男同性恋、双性恋和跨性别者委员会或教育培训了解到该计划。医疗服务提供者使用该计划来制定护理计划、激素治疗建议、性与生殖健康教育、手术治疗教育、医患沟通指导以及寻求第二意见。计划使用的促进因素包括易于理解的建议、通过EHR系统易于使用以及作为农村医疗服务提供者唯一的跨性别者资源。使用的障碍包括时间限制、与电子咨询相关的沟通问题、对资源不足站点不切实际的建议以及对电子咨询目的的误解。改进建议包括增加简洁或分节的回复、在医疗服务提供者或患者中扩大计划知晓度、指定一名后续联系人以及增加医疗服务提供者关于跨性别退伍军人及相关护理的教育。定量分析表明，不使用该计划的常见原因是不了解该计划（54%）、不需要该计划（32%）以及从电子咨询之外的同事那里获得了帮助（24%）。定量分析中关于改善计划使用的常见建议包括提供更多关于在图表中何处找到电子咨询的信息、关于与患者谈论该计划的指导以及通过电子邮件通知以提高医疗服务提供者对该计划的知晓度。事后探索性分析表明城乡医疗服务提供者之间没有差异。
VA跨性别者电子咨询计划对医疗服务提供者有用，但在实施建议方面存在一些障碍，其中一些对农村医疗服务提供者尤其具有挑战性。解决已确定的障碍并增强促进因素可能会改善该计划的使用以及为跨性别退伍军人提供的优质护理。
