Improving the usability of Written Exposure Therapy in VA telehealth settings: A formative, exploratory study informed by the Discover, Design/Build, and Test framework (Preprint)

BACKGROUND End user modifications are common in evidenced-based psychosocial interventions (EBPIs) for mental health disorders. Often, EBPIs fit poorly into clinical workflows, require extensive resources, and/or pose considerable burden on patients and providers. The implementation science field is increasingly researching ways to improve the usability of EBPIs prior to implementation. User-centered design (UCD) can be used in support of implementation methods to prioritize end user needs and solutions to improve EBPI usability. OBJECTIVE Trauma focused EBPIs are a first-line treatment for patients with posttraumatic stress disorder (PTSD) in the Department of Veterans Affairs (VA). Written exposure therapy (WET) is a brief, trauma focused EBPI in which patients handwrite about a trauma associated with their PTSD. Initially developed for in-person delivery, WET is increasingly being delivered virtually, and outcomes appear equivalent to in-person delivery. However, there are logistical issues delivering WET via telehealth. In this evaluation, we 1) explore usability issues related to WET telehealth delivery and 2) design a solution for end-user challenges to systematize WET telehealth delivery. METHODS This formative evaluation was guided by the Discover, Design/Build, and Test (DDBT) framework and served to inform a larger Virtual Care Quality Enhancement Research Initiative (QUERI) program. We used qualitative descriptive methods in the Discover phase to understand the experiences and needs of two groups of end users providing care within VA: 1) in-person providers delivering WET virtually because of the COVID-19 pandemic and 2) telehealth providers who regularly deliver PTSD therapies. We then used UCD methods in the Design/Build phase to brainstorm, develop, and iteratively refine potential workflows to address identified usability issues. All procedures were conducted remotely. RESULTS In the Discover phase, we found both groups had challenges delivering WET and other PTSD therapies via telehealth due to patient/provider technology issues, environmental distractions, and workflow disruptions. Narrative transfer (i.e., patients sending handwritten trauma accounts to providers) was the first target for design solution development as it was deemed most critical to WET implementation. In the Design/Build phase, we identified design constraints and brainstormed solution ideas. This led to the development of three solution workflows that were presented to a sub-group of end users via cognitive walkthroughs. Meetings with this sub-group allowed us to refine the workflows to improve narrative transfers between patients and providers. Finally, to facilitate using these workflows, we developed PDF manuals (one for patients, one for providers) that will be refined in subsequent phases of the larger implementation project. CONCLUSIONS DDBT can be a useful tool for understanding end user needs in complex EBPI interventions, and for designing solutions to end-user identified usability issues. Building on this work, an iterative evaluation of the three solution workflows and accompanying manuals is underway as part of a nationwide WET implementation in telehealth settings.