Implementing Measurement-Based Care in Virtual Mental Health Services for Rural Veterans: Provider Insights from a Pre- Implementation Evaluation

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Although MBC improves outcomes when results are discussed collaboratively, adoption across the Veterans Health Administration (VHA) remains below 50%, particularly in virtual and rural settings. This pre-implementation evaluation explored provider perspectives to inform development of a digital MBC workflow for rural tele-mental health settings. Methods: Using the Alacrity Center’s Discover, Design, Build, and Test model and User Centered Design, we conducted a pre-implementation survey of mental health providers at a VHA Medical Center providing care to rural and highly rural Veterans in Southcentral United States. Providers represented disciplines of psychology and social work. The survey contained structured and open-ended questions assessing prior MBC use, perceived benefits and drawbacks, and educational needs. Qualitative data underwent inductive thematic analysis by two independent coders using consensus review to identify emergent themes. Results: Forty-six providers identified three key benefits of MBC: enhanced symptom awareness and monitoring, support for data-informed treatment planning, and facilitation of patient engagement and shared decision-making. Reported barriers included time constraints, inconsistent Veteran participation, functionality of digital tools, and challenges in interpreting and integrating results. Providers also expressed concern over the accuracy of self-report measures and potential negative psychological effects of repeated symptom tracking. Educational needs clustered around three domains: (1) psychometric understanding of measures, (2) effective communication of results with Veterans, and (3) practical guidance on integrating digital tools into workflow. Illustrative quotes are presented verbatim. Conclusions: Provider feedback underscores that successful MBC implementation in digital mental health requires not only technological infrastructure but also targeted provider education and psychoeducational tools. Training should emphasize interpretation of assessment data, patient-centered communication, and safe, ethical management of sensitive results. Embedding MBC within a structured digital workflow supported by provider-informed design can enhance engagement, streamline care, and align with VA’s goal to expand high-quality, data-driven mental health services for rural Veterans. Given the quality improvement context, findings should be interpreted as context-specific insights used to shape local implementation rather than generalizable evidence. Measurement-Based Care Veterans Health Administration Veteran mental health rural healthcare tele-mental health digital workflow quality improvement telehealth digital mental health provider training Background Effective mental health treatment increasingly emphasizes ongoing evaluation and data-driven decision-making approaches, such as measurement-based care (MBC), to guide clinical practice and improve outcomes. MBC in mental healthcare entails the repeated administration of standardized psychological and psychiatric symptom assessment measures completed by patients to monitor treatment response and inform subsequent care decisions. MBC, a cornerstone of evidence-based care, contributes to learning health system approaches when its data are aggregated at the clinic or network level 1 , 2 . However, the potential of MBC cannot be realized if it is not implemented effectively or provider adoption is low. It is estimated that less than 20% of mental health providers nationwide use MBC 3 , 4 , 5 . Considerable evidence indicates that MBC only improves clinical outcomes when both the patient and provider receive results and openly discuss them to inform treatment decisions 6 , 7 , 8 , 9 , 10 . To date, healthcare systems implementing MBC at scale struggle to meet this best practice 11 . In a 2015 meta review by Krageloh et al., findings underscore the importance of providers reviewing results collaboratively with patients for MBC to have clinical impact 10 . However, even systems that collect psychological measures and report results to patients and providers often fail to integrate results into care discussions. The Veterans Health Administration (VHA), the largest healthcare system in the United States, has a national office promoting MBC to improve services for Veterans receiving mental health care. VHA’s model uses a "Collect, Share, Act" framework 12 to emphasize that coordination of all three key components is required to achieve better treatment outcomes. A 2019 VHA study found only 15% of patients had MBC assessments despite a concerted use of proven implementation strategies by VA’s Office of Mental Health 13 . Even with nationwide efforts by VHA to support MBC use, widespread provider adoption of telehealth-delivered MBC (tMBC) within VHA has not yet been achieved. Challenges to tMBC adoption in rural VHA Community-based Outpatient Clinic (CBOC) settings extend beyond the challenges faced in adoption of MBC delivered in person. Historically, utilizing MBC during VHA telemedicine encounters required : 1) verbal administration of the tool by the clinician, 2) the patient held a completed paper version of the assessment up to the camera, or 3) staff fax the completed assessment to the VA Medical Center (VAMC), where data is entered manually. VHA has aimed to support providers by developing mobile health applications, including the Behavioral Health Lab Touch® (BHL Touch) decision support software 14 , 15 , to transition the collection, analysis, and sharing symptom trajectories with patients from paper and pencil to an electronic platform. This shift aligns with civilian practices, with numerous digital platforms being developed and implemented to support tMBC 16 , 17 . However, inconsistent implementation, provider education, workflow integration, and tool utilization persist 18 ;the two main usability barriers are inadequate informatics support and workload/time burden 19 , 20 , 21 , 22 . VHA CBOC facilities often lack adequate staff or informatics support to facilitate a tMBC workflow in virtual care delivery and as a result opportunities for optimal care are limited by low rates of MBC adoption by tele-mental health providers for rural Veterans. Our quality improvement (QI) project “Virtual Care QUERI Program: Implementation of Technology Facilitated Evidence Based Practices to Improve Access to High Quality Care for Rural Veterans ” (project number QUE 20 − 007) was funded by VA’s Quality Enhancement Research Initiative, a national program that partners with VHA providers, leaders, and Veterans to broaden reach and adoption of evidence-based practices across the United States 23 . The project emphasizes Krageloh et al.’s mandate that MBC go beyond the collection of questionnaires to a process in which results are actively shared and discussed 10 . Too often, these measures are completed but never reviewed with patients, and at times, not even by the provider. The aim of this project was to improve rural Veterans’ access to MBCby optimizing digital delivery and adapting workflows for tele-mental health providers while maintaining the three core components as specified in existing VHA MBC Implementation Guidelines: 1) COLLECT repeated assessments over time, 2) SHARE results between patient and provider during the encounter, and 3) ACT upon data in treatment decisions after reviewing patient trajectories over time. Designed prior to the COVID-19 pandemic, this QI project sought to collaborate with VHA Mental Health Service Lines, comprised of a VAMC and its affiliated CBOCs, to establish a feasible, efficient, and secure digital workflow for patient assessment and results review when using telehealth. The prospect of an efficient digital workflow process revealed the valuable role of digital health innovations in extending evidence-based mental health services to Veterans in geographically remote areas. As project implementation began during the COVID-19 pandemic, when in-person meetings and direct patient care were significantly limited, the project’s timeliness and salience to VHA tele-mental health care, in general, was serendipitous. This QI project developed and refined an intervention to improve uptake of MBC among VA mental healthcare providers. This pre-implementation evaluation explored provider perspectives on barriers, facilitators, and educational needs related to adoption of tMBC in virtual mental healthcare delivery. This manuscript reports on qualitative findings from a pre-implementation survey conducted during the Discover phase and how results informed subsequent stages of the project. Methods Study Design Guided by the ALACRITY Center’s Discover, Design, Build and Test model 24 and User Centered Design 25 26 , the project initially proposed to conduct in-person site visits to complete qualitative interviews and direct observations of clinician routines to map clinical workflows. However, in response to evolving clinic-wide practices during the COVID-19 pandemic, the project was adapted by leveraging the virtual platform Microsoft Teams to allow the project team to attend virtual staff meetings at participating sites. These monthly virtual meetings with clinic teams became the primary venue for implementation and training activities. The initial meeting was used to orient providers to the project and complete a baselines assessment of the providers’ perceptions of and experiences with MBC. Subsequent monthly meetings included a variety of feedback loops and educational topics. Feedback loops comprised a presentation of survey results, workflow redesign discussions using “think aloud” protocols to determine how to breakdown MBC sub-components and troubleshooting key barriers. Educational components included overviews of the VHA’s “Collect, Share, Act” framework, the Behavioral Health Lab® (BHL) technology for electronic assessment capture, case presentations, and the dissemination of a curated library of available assessments. To address known barriers to adoption 19 , 20 , we expanded upon VHA’s MBC Implementation Guide by more fully promoting electronic data capture to reduce workflow burden. At the end of participation, a final meeting featured a wrap-up to consolidate learning and plan for maintenance. Project participation lasted 6 months. This structured approach allowed the program to be flexible yet consistent by embedding MBC within digital health infrastructures to support VHA’s mission to expand high-quality, data-driven care, particularly for rural and underserved Veterans. This QI project was determined to be non-human subjects research by the University of Iowa Institutional Review Board. Per VHA Handbook 1200.21 (Veterans Health Administration 2019), all VA authors of this manuscript attest that the activities that resulted in producing this manuscript were not conducted as part of a research project, but as part of a non-research evaluation conducted under the authority of the Office of Mental Health. Participants Participants were mental healthcare providers including psychologists and clinical social workers from a VAMC serving rural and highly rural Veterans in the Southcentral US. The service line was identified and recruited by the project lead (CT). Pre-Implementation Survey As part of the Discover phase, we conducted a pre-implementation survey with structured and open-ended questions. Demographic data were collected via closed ended questions. Qualitative data collected in the survey assessed provider opinion on benefits and drawbacks of MBC and education needs related to adding MBC to the provider’s clinical toolbox. Survey items were developed de novo by the multidisciplinary project team to align with the objectives of the pre-implementation evaluation. The survey was collaboratively refined by team members representing clinical (CT, AH, MR) and implementation science (AH, LF) expertise to ensure relevance and face validity within the VHA context. Consistent with the rapid and iterative nature of QI work, the survey was not pilot tested prior to administration. Data was collected in August 2023. An electronic survey link, distributed via Qualtrics, was sent to 57 providers who were in attendance of the initial project meeting. Consent was implied via survey participation. The full survey is available as Appendix 1. Analysis Data obtained through Qualtrics was downloaded into Microsoft Excel and imported into SAS for data cleaning, management, and analysis. Descriptive statistics, including frequencies and summary measures, were used to analyze the characterological data of participating providers. All data were de-identified prior to sharing, and VHA secure data storage protocols were followed. All analyses were performed using SAS 9.4 27 . Descriptive statistics were used to analyze the demographic data of participating providers. Inductive thematic analysis 28 , 29 was applied by two members of the project team (AH, CT) to the qualitative data. Emergent themes were identified through the development of a codebook. To develop the codebooks, AH and CT together systematically reviewed 5 responses from each question, discussed key concepts, and agreed upon codes. The remaining responses were coded individually by CT and AH, iteratively developing the codebook until no new codes were identified and saturation was reached. A team meeting was held to achieve consensus when clarification was needed to address or revise codes. Data analyzed for this manuscript was utilized in an iterative feedback loop supporting the ongoing QI project. The timely analysis of this data was important to inform the Design phase. This manuscript was developed in accordance with the Standards for Quality Improvement Reporting Excellence guidelines 30 (Appendix 2). Results A total of 46 staff members participated in the electronic survey, including psychologists (n = 28), licensed clinical social workers (n = 17), and a non-licensed social worker (n = 1). Of the participants who shared information on their age, 54% were aged 40–59, 37% were aged 25–39, and 2% were 60+. Results presented here are organized by perceived benefits, drawbacks, and educational needs related to MBC. The identified sub-themes provide insight into the nuances of implementing MBC and integration of the practice into clinical workflows. Quotes are reported verbatim (written). Benefits Many benefits of MBC were reported by participating providers and are organized across three subthemes: symptom awareness and monitoring, guiding clinical decision making, and facilitation of care delivery. Symptom awareness and monitoring Twenty-six participants reported the benefit of symptom awareness and monitoring, including identification of symptoms, illumination of severity of symptoms, and the ability to easily track symptoms over time. Eleven participants reported that the assessments help identify symptoms that were not revealed during clinical interactions, with one provider sharing, “[MBC] Helps to guide the treatment and open a forum for discussing specific symptoms that may otherwise go unnoticed” [ID007]. Another provider explained, “It helps determine what symptoms may be more prevalent in a patient's situation. The Veterans are usually not aware of the degree of their depression for instance until they complete the PHQ-9” [ID0036]. Another noted, “ [MBC] helps you to be thorough and not miss symptoms in your assessment of current concerns” [ID0040]. Insight into symptom severity can be helpful in ongoing treatment planning, and as noted in the survey responses, Veterans may not be aware of the severity of their symptoms. One provider spoke to the benefit of quantifying symptom severity, expressing that MBC “Puts symptom severity into an easier to understand number” [ID0028]. One provider summed up the benefits of symptom awareness and the subsequent opportunity for guidance in treatment decision-making, stating, “Significant benefits are diagnostic clarity, current snap shot of "mental coordinates", opportunity to discuss current factors, see improvement, make adjustments, understand their thought process and why they answer the way they did, provides feedback and other data such as habit and automatic thought process" in responses if there are not any changes” [ID0035]. Guiding Clinical Decision Making MBC can guide clinical decision-making through objective tracking of symptom change (or lack thereof), identifying progress toward care goals, and informing treatment and, ultimately, discharge planning. Providers noted benefits of collecting assessment data, indicating that when first administered the assessment results give a baseline from which the response to treatment can be monitored. One provider shared, “ It allows you to better understand the patient and gives you a baseline at which to measure the efficacy of treatment ” [ID0041]. As data collection continues over the course of treatment, progress can be measured and viewed in a more objective manner. According to one provider, “It helps provide additional data to patient and clinician's subjective experience and judgement to determine the effectiveness in treatment” [ID0033]. This objective understanding of the symptom change was noted as important by participating providers. Providers spoke about how MBC’s provision of insights into nuanced symptom changes is valuable for treatment planning by helping to refocus goals and priorities and support patients’ ability to identify and act on areas of concern. According to one provider, MBC “provides a structure for involving the patient in a discussion regarding progress (or lack of)” [ID0002]. Other providers spoke about how MBC is good for identifying unmet needs, noting MBC helps with “ tracking progress relative to goals [and to] identify sources of support needed that may not be being addressed by the current therapy” [ID0009], and “For me and the patients to track their progress over time and see when therapy is making a difference and if not, where they may be stuck” [ID0010] . Respondents reported how the psychoeducation component of MBC is a valuable tool in helping patients to better understand their diagnoses and symptom severity. “Given the need for episodic care and the frequency with which Veterans present with complex, chronic problems, I think use of MBC can help both Veteran and provider feel clear and satisfied about progress in treatment. I work almost exclusively with patients with chronic issues because of my specialty and use of measures helps educate patients that fluctuations in symptoms do occur and help them think about quality of life beyond symptom focus” [ID0039]. Outside of the psychotherapy realm, one provider spoke about the value of MBC can be for psychotropic medication management. “For veterans that are taking medications, if working, then I want to see their symptoms to be moderate to mild vs. moderate to severe. Then it can indicate a need to review medications to either increase dosage, maintain the dosage or even lower dosages at times” [ID0036]. Facilitation of Care Delivery Providers conveyed that MBC facilitates engaging Veterans in treatment, supports rapport building, saves time and helps Veterans move toward acceptance of a clinical diagnosis. Helping Veterans feel more engaged in their own treatment was noted to be a benefit among many providers. Providers articulated important insights into their perceived value of MBC saying, “completing the assessments during session strengthens partnership” [ID043], that MBC “ … helps patients feel more involved in their own care” [ID0004], “ validates a Veteran’s experience ” [ID0011], “ [provides] better education about mental health conditions” [ID0012], and “ can help people improve their self-monitoring and self-awareness of different symptoms and make links between symptoms and an overall diagnosis.” [ID0038]. Time was discussed in the report of benefits of MBC. MBC was reported as being a time-saver by some, but not all providers. One provider shared “The biggest benefits of MBC are its use during intake assessments (almost as a "short cut" during these long assessments to help with time management) ” [ID0006]. Time was also discussed in the context of being able to identify problem areas and make change right away, “ Being able to track progress and act on areas of concern right away is invaluable. This is one of the other major pros of MBC ” [ID0019]. In addition to the clinical benefit of MBC, some providers described adjunctive benefits, specifically how MBC processes can act as a facilitator of care. One beneficial factor associated with successful uptake of clinical interventions is the ease with which individual technological systems (i.e. BHL Touch and VHA’s electronic health record (EHR)) work cohesively in support of the intervention. Some providers discussed the ease with which MBC can be integrated into video telehealth visits with one provider indicating that BHL touch provides an advantage in MBC, stating “ Since I started using BHL touch, I no longer feel I have a disadvantage to face-to-face providers (who can hand a form to a client, have them fill it out, then look it over later)” [ID0006]. Providers also pointed out the added benefit of the text message sent to collect symptom data acting as a secondary appointment reminder. Drawbacks Providers’ reports on the drawbacks of MBC spanned three categories: assessment completion and self-report bias, structural barriers to provider engagement, and obstacles to evidence-based practice model adherence. Assessment Completion and Self-Report Bias Providers reported a drawback of MBC is that Veterans do not always complete the assessments, noting the circumstances in which this happens and a variety of possible reasons. Although reasons for non-participation are unique to each Veteran, providers cited a variety of perspectives as to why some Veterans may not complete assessments, including MBC not aligning with a Veteran’s goals, provider concerns about MBC having a negative impact on a Veteran, the possibility of self-report bias or response distortion, discouragement from stagnant scores or negative trends, and fear of impact on VA disability benefits. Incomplete assessments were reported to be expressly difficult in digital settings, with one provider describing how, “when using during a telehealth visit- it can be hard to get compliance when asking them to do it prior to the session” [ID0026]. Providers noted that perhaps Veterans are inconsistent in completing assessments due to the Veteran’s perspective on the value of MBC. Some providers reported that the number of instruments used and the frequency of assessment places a burden on some Veterans, leading to MBC feeling “ clunky ” and “less personalized for patient care ”. One provider shared “Patients won't always respond or get frustrated with doing them.” [ID0046]. The value of MBC is not always realized immediately among Veteran patients, making it difficult to get “Veteran buy in” to see the benefits of the treatment. Concerns about negative psychological impacts on Veteran patients were communicated. The psychological impacts described included frustration, demoralization, discouragement, and anxiety provocation. One provider shared their experience that “For some Veterans, it reinforces how poorly they are doing to fill the questions out week to week…and it raises anxiety to fill out the questionnaire about how their anxiety is. There are cases where the measurement process really bothers Veterans. In those cases, I make adjustments rather than disqualify them from an evidence-based practice (assuming there are not other issues such as non-compliance from homework or high resistance to the structured session format)” [ID0006]. Further speculation on how MBC may impact the Veteran was conveyed by one respondent saying “Some people communicate that seeing the numbers can elicit shame or discouragement that they are not improving, even though people in therapy tend to get worse before they get better” [ID0038]. Providers conveyed apprehension in accuracy of reported symptom data, due to self-reporting bias and reporting distortion. In some cases, inaccurate symptom data may be due to questions not being specific enough or fatigue in filling out the assessments. One provider expressed how MBC can create difficulties in the session, noting that issues arise “ When Veterans want to add to the questions because they are not specific enough or when Veterans elaborate too much on each question or get frustrated by questions (especially in longer assessments, like BASIS 24 and IMRS” [ID0022]. Some providers posited that response distortion may be influenced by a desire to seem better than they are or by a fear of reduction in benefits due to improvement. In these cases, providers indicated reticence to use MBC. Regarding reporting that may minimize appearance of symptom burden, one provider stated, “ Some veterans ‘fake good’ and engage in more denial and minimization of symptom, so the numbers are reflective of what they report in sessions.” [ID0038]. Further concern about self-report bias and response distortion was raised around the issue of suicidality. “Patients learning how to respond to the measure to avoid having difficult conversations or hospitalization. For example, a veteran might learn that if they endorse having suicidal thoughts, they will get follow up questions that might lead to being hospitalized. Rather than saying, ‘I need to have this conversation,’ they choose to deny having any suicidal thoughts. Alternately, some veterans tell us what they think we want to hear rather than how they actually feel because they want to be perceived as doing well in therapy or on a test (yes, scholastic assessment carries over for a long time!)” [ID0041]. Alternative ideas were offered to explain response distortion, with one provider sharing, “ Some patients who are therapy dependent react negatively to the positive outcomes. Some patients learn to answer negatively because they think that will keep them in therapy longer or look better for disability claims ” [ID0043]. Leaning into the concerns about disability benefits, one provider responded, “Possibly some Veterans will over-report out of concern that their service connection could be impacted (though I think this is a minority in actuality)” [ID0007.] Another stated, “some Veterans are hesitant to answer honestly for fear of reduction in disability/benefits time” [ID0037]. Structural barriers to provider engagement Providers cited structural barriers to using MBC, including concerns over asynchronous collection of time sensitive data (i.e. suicidality screening), functional and technical constraints of software used to support MBC, and overall time constraints. Three instances were offered as examples of problems that arise due to asynchronous MBC. The first concerned timing and coordination with the EHR scheduling software. Providers noted that confounds arise when a Veteran completes their assessments ahead of time but then cancels or misses the appointment, as their assessment data then lacks an associated clinical visit and cannot be uploaded. The next concern about asynchronous assessment also related to cancellation but referenced the burden on the provider to keep track of what forms were sent out if a Veteran cancels and reschedules an appointment. Finally, results from an asynchronous assessment of symptoms may trigger the need for emergent follow up, which is problematic when follow up contact with the patient is unsuccessful. Clinician responses to a positive suicide screen gathered during asynchronous assessment may need to be dynamic, as the symptom measures are not always sensitive to acute versus chronic suicidal ideation, both of which can occur in Veterans accessing care. Providers conveyed the need to navigate legal and ethical clinical practice standards when working with individuals who report suicidality. Various functional and technical constraints were identified by participating providers. The library of assessments offered within BHL touch was noted by several providers to lack assessments that are needed for some patients. Some providers still utilized assessments that were not in BHL touch, with one respondent stating, “I have been finding other ways to readily integrate other, more relevant measures into my practice that are not a part of the VA catalogue. But this does create issues with time in session, especially for Veterans who are being seen virtually and cannot fill out the measure in session” [ID0033]. One provider described workflow inefficiencies when standardized assessments are not available through BHL Touch, noting that alternate methods (e.g., email or patient portal) often reduce response rates and require using valuable session time to complete measures that could otherwise be done independently. There are times when something is not on BHL touch, and in those cases, I have to e-mail or MHV [My HealthEVet, patient portal] the info (which then I typically don't get anything back) or I have to complete the assessment verbally (which takes session time I prefer to spend doing something non-standardized). For example, I am a provider in an OCD study which asks for the Y-BOCS to be filled out 1x/2 sessions. I have to e-mail rather than have a text sent, and the Veteran tends to fill it out in session with me rather than getting it done ahead of time. When I use BHL touch for the same Veteran to complete a PHQ and PCL, they typically get it done outside of session [ID0006]. Technical issues reported were related to software malfunctions, accessibility (if a Veteran’s device does not allow them to see the provider or screen during a video visit), and the impact of technical failures on the provider and patient relationship. One provider expressed, “When it doesn't work, it can be very frustrating (this can be especially important during an intake assessment when there may be high suspicion or nervousness coming into the appt)” [ID0006]. Concern about technological proficiency among Veterans was reported as a barrier to MBC. Some providers reported a lack of confidence in their Veteran-patients’ ability to access and navigate the technology used by VHA in MBC (i.e. BHL Touch). On the other hand, one provider spoke about how providers need to be able to respond to Veteran’s preferences, “i n this day and age the patients dictate the level of technology they are comfortable with yet as providers we need to be familiar with all options” [ID0036]. Time as a Barrier Issues around time as a barrier to uptake of MBC were reported among numerous respondents. When queried about the potential drawbacks of MBC, some providers simply responded with one word, “ time ”. Others shared more nuanced perspectives, noting that the time required to complete surveys during sessions and to review the data for discussion and treatment planning impacted adoption. One provider explained, “ the biggest problem I have is time required if the assessments are completed in session. BHL is a great tool, but Veteran compliance varies” [ID0002]. Time as a barrier crossed over with reported Veteran engagement issues, with one provider noting, “ it does take session time and often patients aren’t as interested in that as other things, so it feels like a struggle to make them do MBC stuff” [ID0039]. Another provider suggested that time constraints are related to reviewing and planning, stating a barrier to adoption is “ needing the time to review the assessments. Needing the time to adjust the course of overall treatment when assessments suggest so” [ID0024]. The concern for time was not universal, with one provider stating “I don’t know of any drawbacks. Time is really not an issue when you get used to it” [ID0019]. Despite that provider’s enthusiasm, the sentiment was not universally shared and participating providers offered important insights into the drawbacks of MBC that impact its usability in clinical care. Measure Validity and Therapeutic Value Provider reports on barriers to fidelity to MBC as an evidence-based practice included not always understanding the therapeutic value of MBC, the predictive validity of specific measures and their sensitivity to change over the course of treatment, and how to respond clinically when Veteran’s scores did not indicate clinical improvement. For example, providers relayed their perception that scores are not necessarily always accurate, that “ measures don’t always accurately capture change ” [ID0020], and that since the assessments are symptom focused, MBC “ does not always capture important qualitative elements of change (e.g. sense of confidence, improvement in relationships, sense of social connectedness, movement toward personal life goals like applying for jobs or school). Some therapy goals may be more interpersonal and less symptom focused, or some symptoms may be expected to demonstrate less overt change that can be tracked easily, such as personality disorders or SMI [serious mental illness]” [ID0041]. One provider indicated that sometimes assessment scores do not match the lived experiences of Veterans, stating “ although the scores can be helpful on eliciting more discussion about certain symptoms I don’t think they are necessarily very accurate for various reasons; i.e. the Veteran’s perception of their score upon further discussion does not always match what one would assume if just looking at numbers” [ID0026]. Beyond concerns about item or total score validity, therapeutic value of MBC processes was also explored by participating providers. Specifically, assessment cadence (e.g., how frequently the assessments are sent out) raised two concerns among providers in two ways: that weekly assessments posed an undue burden on Veterans and that changes in symptoms were less noticeable when measures were obtained more frequently. Stagnation or Decline Providers expressed concerns about the potential for challenges navigating clinical care, for the clinician or the Veteran, when a Veteran’s symptom scores lack of evidence of clinical improvement. One provider stated that their perceived negative impact on the Veteran hindered their use of MBC because of the potential drawback due to demoralization, sharing “Demoralization if their scores don’t change. If there are structural reasons the treatment will need to end (i.e., come to end of protocol, etc.) and the scores are not improved, it makes it hard for the clinician to handle that clinically. My interest in it at a program/team/clinic level is hard because most people don’t use it. So it’s hard to get the data I want from it. And then over time, it impacts my own individual motivation to use it” [ID0039]. Some providers shared their concerns about their performance evaluation based on patient outcomes. One provider reported, “ I have heard providers express concern that their clinical performance/efficacy will be judged according to the Veterans' MBC results” [ID0007]. Another shared, “They are not the end all be all. There are a variety of reasons why someone may score a certain way and that needs to be discussed and taken into account. At times it feels like VA places too much emphasis on MBC being the main driving indicator of therapy success” [ID0011]. Educational Needs Providers requested training in psychometric properties of assessments to inform selection and interpretation, how to talk to Veterans about the Collect, Share, and Act components of MBC, and workflow and integration into their own practice. They asked for small-group or step-by-step training, workflow guidelines, and a full assessment directory. Respondents spoke about the need for good training in MBC, with one provider sharing her belief that when MBC is used by providers who are poorly trained, it leads to poor patient experience. Assessments selection and interpretation Two overarching educational needs around assessment selection and interpretation were identified: 1) awareness and understanding of assessments and psychometric properties to inform selection and interpretation and 2) knowing which assessments best capture symptom burden related to specific diagnoses. Providers broadly indicated a need for a better understanding of what is available, with one provider suggesting the desire for a “directory of measures”. One provider asked for a “ resource including what other providers use when treating a specific condition and why” [ID0001]. Another provider spoke to the gap in available assessments, reporting, “I am having problems finding a good assessment tool to use for anger management. Most published measures regarding anger are ‘trait’ measures rather than a ‘state’ measure and not that useful for repeat assessment” [ID0002]. Beyond awareness of what is available, providers shared that to feel more confident in using MBC, they need to better understand psychometric properties of the assessments available on BHL touch and what constitutes clinically meaningful change in scores. Several providers emphasized the need for additional guidance on how to interpret assessment results and apply them meaningfully in treatment, noting that further training would help them use these tools more effectively. Specifically, how they as a provider can translate scores into treatment planning. One provider noted that a barrier to adherence was “ Not fully understanding the meaning gained from some assessments ” [ID0024]. Others described what would help them, sharing they would like “Education on the specific meaning/interpretation of the assessments and how they could inform the treatment and give meaning to Veterans for the major assessments ” [ID0024], and “ Training to better help the providers to understand the results of the tools and how to utilize them effectively in treatment” [ID0042]. One provider reported a detailed and insightful educational need related to understanding the minimal important difference for the measures, stating that education would be helpful on “What are statistically significant changes in total score for some of the more common measures (PHQ9, GAD, PCL, CESD). I.e. I think I've heard 5 pts for phq9 but I am not sure so this is just a fake example: Say you are working with a pt with a depression goal and although your pt's total score improvement did not trend at/below minimal depression, but say they had a (greater than) or = 5 pt reduction in total score from 18 to 12 and this is deemed statistically significant for this measure meaning that they likely saw a meaningful change and this is still considered a successful episode of care...” [ID0045]. A need for nuanced education around selection and interpretation of assessments that best measure symptoms associated with particular mental health conditions or patient circumstances was reported. Personality disorders were identified as challenging diagnoses for utilizing MBC, as some providers indicated it is difficult to find assessments that are time-sensitive, as many assessments of personality disorders are lengthy, and that are sensitive to the discrete symptom change that is anticipated in treatment of personality disorders. Provider-delivered psychoeducation Providers consistently asked for education on how to discuss MBC with Veterans. Specifically, providers want to know how to explain the meanings and interpretations of the assessments, how to inform Veterans on the impact of their results on the treatment options, how to discuss symptom changes (or lack thereof), and how to make discussing MBC more relatable to the Veteran patient., One provider responded, “ How to show results of assessments over time over VVC [VHA’s Video Chat], just some discussion about helpful ways to talk about use of measurements with Veterans, and education about how to best use some of the measures (info about the purpose, data about reliability/validity)” [ID0032]. Some providers sought nuanced education on specific topics, such as how to discuss scores that do not align with patients’ narrative reports or how to address changes over time, effective implementation when caring for patients presenting with therapy blocking behaviors, or who may be experiencing higher levels of distress in an outpatient setting. One provider noted the need for education related to caring for patients with particular diagnoses, sharing “ MBC troubleshooting for certain presenting concerns -- for example in the DBT [Dialectical Behavioral Therapy] team, where treatment can last for a year, we don't have great options for MBC for patients with BPD [Borderline Personality Disorder]- we have tried a range of them like the DERS [Difficulty in Emotion Regulation Scale], BSL-23 [Borderline Symptom List 23]- none of them capture what we want to track for individual patients and other measures are not available on MHA [Mental Health Assistant] /BHL/VHA system. Other personality disorders as well - not a lot of brief options for tracking change in the first place (generally extremely lengthy!), and PDs [Personality Disorders] may not be expected to show significant changes in discrete symptom count” [ ID0040]. Workflow and Integration into Clinical Practice Providers reported broad educational needs related to workflow, varying from broad requests of “ anything to streamline the workflow ” [ID0007] to a “ step-by-step process ” [ID0028]. Education needs around the technology varied. Some providers reported a need for fundamental training on the use of BHL Touch software, such as how to log in, send the surveys to the Veterans, and integrate the assessments into the EHR. One provider requested education on how to work with BHL to add assessments to the library, stating “ Getting more measures built into the programs. I have a niche measure for my ADHD patients that others might find very insightful, but it's not on any of the MBC programs. I have to deliver it via WebEx Poll any time I want to use it, which is very cumbersome and time consuming, but worth it” [ID0041]. Another issue providers reported needing help navigating is more than one licensed independent practitioner (LIP) may be using MBC with the same patient, with one provider asking for information on “ which LIPs should be administering them ” [ID0036], speaking to the nuances of engaging in MBC in a multidisciplinary setting. Discussion This qualitative inquiry to assess provider perceptions of MBC to inform development of a digital MBC workflow in a tele-health setting revealed nuanced views of its clinical utility, barriers to adoption, and areas for provider training—directly addressing the initial research aim. Findings demonstrate the intersection of digital health implementation and behavioral healthcare delivery, highlight the nuanced factors influencing tMBC adoption in VHA telehealth settings, and underscore how workflow integration and user-centered design remain critical determinants for successful adoption of digital tools in telehealth environments. In descriptions of the benefits of MBC, providers recognized its potential to enhance symptom awareness and monitoring, support treatment planning, and facilitate patient engagement in therapy. Regarding barriers to uptake of tMBC, they shared persistent barriers that limited routine use such as time constraints, inconsistent Veteran participation, functionality of digital tools, and challenges in interpreting and applying results. Educational needs reflected barriers identified, with requests for training centered around psychometric proprieties of measures, effective communication strategies with Veterans, and guidance on integrating digital tools into workflows. Consistent with prior implementation studies, providers emphasized a need for structured guidance on communicating results to Veterans—a gap that may be addressed through MBC-specific psychoeducation tools. Providers requested language that could specifically be used in clinical encounters to help a Veterans understand the clinical intervention. Based on this feedback, it was determined that providers need training and ongoing clinical support on how to provide psychoeducation on MBC that effectively educates the Veteran patients on all components of this clinical intervention, ranging from risks and benefits of the treatment method to sharing results that provide insight into the illness and meaningfully impact treatment decisions. Psychoeducation is a vital element of widely used psychotherapeutic models like Cognitive Behavioral Therapy 31 , 32 , Dialectal Behavioral Therapy 33 , Acceptance and Commitment Therapy 34 , and Psychodynamic Psychotherapy 35 . Mental health providers who use these models during therapeutic interventions have been taught how to provide psychoeducation in the context of that model through manuals, training, certification courses, etc. However, there is a gap in the literature regarding how to provide psychoeducation specific to the MBC model 2 , 36 , 37 , 38 . Similar challenges have been reported in other disciplines- such as physical therapy 39 , occupational therapy, and physiotherapy 40 -that also integrate assessment and measurement into routine clinical care. Concerns about how to manage suicidality disclosures highlight the need for standardized communication protocols and informed consent procedures within digital MBC workflows along with ongoing clinical support for individual cases. Across the United States, organizations vary widely in their approaches to responding to a positive suicide screen, ranging from follow up phone calls to welfare checks to mandatory hospitalizations, and other forms of intervention. Across VHA, providers using MBC work on interdisciplinary teams, with each discipline having their own best practices for responding to positive suicide screens whilst working together to ensure overall best care and safety of a Veteran. In discussing the measures selected for a patient, providers have an opportunity to educate the Veteran about the implications of a positive responses on suicide-related items. Successful adoption of MBC must include education and an emphasis on MBC’s central tenant that clinical symptom rating and other assessment scales are tools to be used in concert with history-taking and clinical judgment, which is always paramount for an effective treatment approach. Furthermore, selection of appropriate assessment tools requires knowledge of the psychometric properties of the individual tools in the context of clinical assessment and clinical judgement. This can be an important factor when providers are considering measures with the potential to capture self-report bias, such as over or under-reporting 41 , which could confound effective treatment. Whether an assessment score stagnates, worsens, or improves, clinicians need reassurance that there is always a need for interpretation of the measurement data in the context of the overarching clinical assessment, including the indications for further inquiry, the use of collateral informants, consultation with other colleagues, and consideration of the appropriateness or validity of the scale/measure for that specific patient’s condition. For example, changes in sleep patterns and the absence of depressive phenomena on the PHQ-9 could reflect cycling from a depressed to a manic state or cognitive decline could impact the ability of a patient to respond using a self-report scale. Implications This study contributes to the growing field of digital health by demonstrating how technology-enabled measurement and feedback systems can enhance the reach and quality of mental health services. Tailored, discipline-specific training modules addressing psychometrics of self-report assessment tools, digital workflow, and communication strategies could enhance provider confidence and uptake. VHA’s infrastructure and data capacity make it a powerful setting for MBC growth, yet the success of MBC depends on equipping providers with the knowledge and confidence to select, use, and apply assessment tools meaningfully. Providers’ experiences underscore how digital tools, such as BHL Touch and VHA Video Connect, serve as digital health enablers, that improve coordination, data flow, and patient engagement—core dimensions of digital healthcare transformation. Embedding MBC within digital health infrastructures supports the VHA’s mission to expand access to high-quality, data-driven care, particularly for rural and underserved Veterans. Strengths and Limitations This study has several strengths and limitations that should be considered when interpreting its findings. A key strength lies in its timely discovery of provider perspectives to inform the design and build phases in a quality improvement initiative within VHA. By capturing provider insights early, the data directly informed subsequent design and workflow adaptations, exemplifying a learning health system approach 1 . The sample included two mental health disciplines serving rural and highly rural Veterans across a large geographic area, offering a rich view of barriers and facilitators to implementing MBC in virtual settings. The use of inductive thematic analysis and multiple coders enhanced analytic rigor and credibility. Nevertheless, the study has limitations. Qualitative data were collected through open-ended survey responses rather than in-depth interviews or focus groups. Although this approach facilitated participation from a geographically dispersed provider group, it limited opportunities for follow-up probing and contextual clarification. Responses may be subject to self-selection and social desirability bias, as providers who were more engaged or favorable toward MBC may have been more likely to participate or to emphasize positive aspects of implementation. The survey was developed de novo and was not pilot-tested or validated, which may influence content comprehensiveness and construct coverage. Finally, the analysis reflects perspectives from providers within one VHA mental health service line and may not be generalizable to all VHA settings or non-VHA health systems. As this work represents the Discover phase of a quality improvement project, findings capture anticipated rather than observed implementation challenges and outcomes. Despite these limitations, the results provide valuable early insights into provider readiness, perceived barriers, and educational needs that directly informed subsequent phases of MBC implementation within virtual mental health care delivery. Conclusion The results detailed in this manuscript informed the development of an implementation strategy that identified core clinical, technical, and administrative requirements necessary for effective, digitally delivered MBC, while allowing for variability across settings and underlying information technology platforms. For this QI project, providers’ nuanced perceptions of benefits, drawbacks, and educational needs was paramount to the Design, Build, and Test phases of the project. This project underscores that while VHA is well-positioned to lead in MBC implementation, adoption is not automatic. A structured, provider-informed, and Veteran-sensitive approach is essential. By educating providers on psychometric properties of assessments and integrating digital tools like BHL Touch with workflows, training, and communication strategies, MBC can become a routine, meaningful part of digital mental health care delivery in the VHA and beyond. As digital health ecosystems continue to evolve, integrating MBC into telehealth delivery offers a scalable pathway to improving mental health care access, personalization, and continuity for diverse populations. Abbreviations BASIS-24 Behavior and Symptom Identification Scale–24 BHL Touch Behavioral Health Lab Touch BPD Borderline Personality Disorder CBOC Community-Based Outpatient Clinic CES-D Center for Epidemiologic Studies Depression Scale DBT Dialectical Behavioral Therapy DERS Difficulties in Emotion Regulation Scale EHR Electronic Health Record LIP Licensed Independent Practitioner MBC Measurement-Based Care MHV My HealtheVet PCL PTSD Checklist (Version 5) PE Prolonged Exposure Therapy PHQ-9 Patient Health Questionnaire-9 PTSD Post-Traumatic Stress Disorder QI Quality Improvement QUERI Quality Enhancement Research Initiative SAS Statistical Analysis System SMI Serious Mental Illness tMBC Telehealth-delivered Measurement Based Care VAMC Veterans Affairs Medical Center VHA Veterans Health Administration VVC VA Video Connect Declarations Ethics approval and consent to participate This project was conducted in accordance with the principles of the Declaration of Helsinki. The project procedures were reviewed by the University of Iowa Institutional Review Board (IRB #202009601), were determined to constitute non–human subjects research and, as such, the need for informed consent to participate was waived. The Iowa City Veterans Affairs Research and Development Committee reviewed and approved the project. Consent for publication Not applicable Funding Our quality improvement (QI) project “Virtual Care QUERI Program: Implementation of Technology Facilitated Evidence Based Practices to Improve Access to High Quality Care for Rural Veterans ” (project number QUE 20 − 007) was funded by VA’s Quality Enhancement Research Initiative. Author Contribution Conceptualization & Design: CT, JF, JLData curation: CT, NS, LF, AH, CH, LMAnalysis: KM, CT, AHFunding acquisition: CT, JFInvestigation: CT, NS, LF, AHMethodology: CT, AHProject administration: CT, NS, LF, AH, CH, LMResources: CTSupervision: CTValidation: CT, NS, LF, AHWriting​: AH, CT, KMWriting – review & editing:​ AH, LF, NS, CH, LM, KM, JL, JF, CT Acknowledgements Not Applicable Artificial Intelligence Portions of this manuscript were edited with the assistance of an artificial intelligence (AI) tool, ChatGPT (GPT-5, OpenAI). Outputs underwent rigorous human review to ensure accuracy, clarity, and appropriateness for scholarly publication. Consistent with International Committee of Medical Journal Editors recommendations 42 , the authors maintained full responsibility for the content and interpretation of the manuscript. The use of AI was limited to language refinement and did not involve interpretation of study data. Data Availability The qualitative data generated and analyzed during the current study is not publicly available in accordance with VA policy governing research data collected within the VA system. Although the study did not involve Veteran patients, the data consists of surveys completed by VA mental health providers and include potentially sensitive information about VA clinical practices, organizational processes, and internal operations. Per VA policy on research data management and access, such data may not be shared outside the VA without explicit authorization and a formal Data Use Agreement approved by the local VA Research & Development Committee. References Friedman C, Rubin J, Brown J, Buntin M, Corn M, Etheredge L, Gunter C, Musen M, Platt R, Stead W, Sullivan K. Toward a science of learning systems: a research agenda for the high-functioning Learning Health System. J Am Med Inform Assoc. 2015;22(1):43–50. 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Supplementary Files Appendix1.MBCQUERIProviderBaselineSurvey.docx Cite Share Download PDF Status: Published Journal Publication published 03 Apr, 2026 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Revision requested 16 Feb, 2026 Reviews received at journal 09 Feb, 2026 Reviews received at journal 09 Feb, 2026 Reviews received at journal 09 Feb, 2026 Reviewers agreed at journal 29 Jan, 2026 Reviewers agreed at journal 28 Jan, 2026 Reviewers agreed at journal 27 Jan, 2026 Reviewers agreed at journal 26 Jan, 2026 Reviews received at journal 24 Jan, 2026 Reviewers agreed at journal 23 Jan, 2026 Reviewers agreed at journal 07 Jan, 2026 Reviewers agreed at journal 06 Jan, 2026 Reviewers invited by journal 06 Jan, 2026 Editor assigned by journal 06 Jan, 2026 Editor invited by journal 06 Jan, 2026 Submission checks completed at journal 05 Jan, 2026 First submitted to journal 05 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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07:38:06","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":19912,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1.MBCQUERIProviderBaselineSurvey.docx","url":"https://assets-eu.researchsquare.com/files/rs-8406956/v1/13ea7520ccf3ef6bc2af3c1f.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Implementing Measurement-Based Care in Virtual Mental Health Services for Rural Veterans: Provider Insights from a Pre- Implementation Evaluation","fulltext":[{"header":"Background","content":"\u003cp\u003eEffective mental health treatment increasingly emphasizes ongoing evaluation and data-driven decision-making approaches, such as measurement-based care (MBC), to guide clinical practice and improve outcomes. MBC in mental healthcare entails the repeated administration of standardized psychological and psychiatric symptom assessment measures completed by patients to monitor treatment response and inform subsequent care decisions. MBC, a cornerstone of evidence-based care, contributes to learning health system approaches when its data are aggregated at the clinic or network level\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. However, the potential of MBC cannot be realized if it is not implemented effectively or provider adoption is low. It is estimated that less than 20% of mental health providers nationwide use MBC \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eConsiderable evidence indicates that MBC only improves clinical outcomes when both the patient and provider receive results and openly discuss them to inform treatment decisions\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. To date, healthcare systems implementing MBC at scale struggle to meet this best practice \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. In a 2015 meta review by Krageloh et al., findings underscore the importance of providers reviewing results collaboratively with patients for MBC to have clinical impact\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. However, even systems that collect psychological measures and report results to patients and providers often fail to integrate results into care discussions.\u003c/p\u003e \u003cp\u003eThe Veterans Health Administration (VHA), the largest healthcare system in the United States, has a national office promoting MBC to improve services for Veterans receiving mental health care. VHA’s model uses a \"Collect, Share, Act\" framework\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e to emphasize that coordination of all three key components is required to achieve better treatment outcomes. A 2019 VHA study found only 15% of patients had MBC assessments despite a concerted use of proven implementation strategies by VA’s Office of Mental Health\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eEven with nationwide efforts by VHA to support MBC use, widespread provider adoption of telehealth-delivered MBC (tMBC) within VHA has not yet been achieved. Challenges to tMBC adoption in rural VHA Community-based Outpatient Clinic (CBOC) settings extend beyond the challenges faced in adoption of MBC delivered in person. Historically, utilizing MBC during VHA telemedicine encounters required : 1) verbal administration of the tool by the clinician, 2) the patient held a completed paper version of the assessment up to the camera, or 3) staff fax the completed assessment to the VA Medical Center (VAMC), where data is entered manually. VHA has aimed to support providers by developing mobile health applications, including the Behavioral Health Lab Touch® (BHL Touch) decision support software\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e, to transition the collection, analysis, and sharing symptom trajectories with patients from paper and pencil to an electronic platform. This shift aligns with civilian practices, with numerous digital platforms being developed and implemented to support tMBC \u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. However, inconsistent implementation, provider education, workflow integration, and tool utilization persist \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e;the two main usability barriers are inadequate informatics support and workload/time burden \u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. VHA CBOC facilities often lack adequate staff or informatics support to facilitate a tMBC workflow in virtual care delivery and as a result opportunities for optimal care are limited by low rates of MBC adoption by tele-mental health providers for rural Veterans.\u003c/p\u003e \u003cp\u003eOur quality improvement (QI) project \u003cem\u003e“Virtual Care QUERI Program: Implementation of Technology Facilitated Evidence Based Practices to Improve Access to High Quality Care for Rural Veterans\u003c/em\u003e” (project number QUE 20 − 007) was funded by VA’s Quality Enhancement Research Initiative, a national program that partners with VHA providers, leaders, and Veterans to broaden reach and adoption of evidence-based practices across the United States \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. The project emphasizes Krageloh et al.’s mandate that MBC go beyond the collection of questionnaires to a process in which results are actively shared and discussed \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. Too often, these measures are completed but never reviewed with patients, and at times, not even by the provider.\u003c/p\u003e \u003cp\u003e The aim of this project was to improve rural Veterans’ access to MBCby optimizing digital delivery and adapting workflows for tele-mental health providers while maintaining the three core components as specified in existing VHA MBC Implementation Guidelines: 1) COLLECT repeated assessments over time, 2) SHARE results between patient and provider during the encounter, and 3) ACT upon data in treatment decisions after reviewing patient trajectories over time.\u003c/p\u003e \u003cp\u003eDesigned prior to the COVID-19 pandemic, this QI project sought to collaborate with VHA Mental Health Service Lines, comprised of a VAMC and its affiliated CBOCs, to establish a feasible, efficient, and secure digital workflow for patient assessment and results review when using telehealth. The prospect of an efficient digital workflow process revealed the valuable role of digital health innovations in extending evidence-based mental health services to Veterans in geographically remote areas. As project implementation began during the COVID-19 pandemic, when in-person meetings and direct patient care were significantly limited, the project’s timeliness and salience to VHA tele-mental health care, in general, was serendipitous.\u003c/p\u003e \u003cp\u003eThis QI project developed and refined an intervention to improve uptake of MBC among VA mental healthcare providers. This pre-implementation evaluation explored provider perspectives on barriers, facilitators, and educational needs related to adoption of tMBC in virtual mental healthcare delivery. This manuscript reports on qualitative findings from a pre-implementation survey conducted during the Discover phase and how results informed subsequent stages of the project.\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003eStudy Design\u003c/p\u003e\u003cp\u003eGuided by the ALACRITY Center’s Discover, Design, Build and Test model \u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e and User Centered Design\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e, the project initially proposed to conduct in-person site visits to complete qualitative interviews and direct observations of clinician routines to map clinical workflows. However, in response to evolving clinic-wide practices during the COVID-19 pandemic, the project was adapted by leveraging the virtual platform Microsoft Teams to allow the project team to attend virtual staff meetings at participating sites. These monthly virtual meetings with clinic teams became the primary venue for implementation and training activities.\u003c/p\u003e\u003cp\u003eThe initial meeting was used to orient providers to the project and complete a baselines assessment of the providers’ perceptions of and experiences with MBC. Subsequent monthly meetings included a variety of feedback loops and educational topics. Feedback loops comprised a presentation of survey results, workflow redesign discussions using “think aloud” protocols to determine how to breakdown MBC sub-components and troubleshooting key barriers. Educational components included overviews of the VHA’s “Collect, Share, Act” framework, the Behavioral Health Lab® (BHL) technology for electronic assessment capture, case presentations, and the dissemination of a curated library of available assessments. To address known barriers to adoption\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e, we expanded upon VHA’s MBC Implementation Guide by more fully promoting electronic data capture to reduce workflow burden. At the end of participation, a final meeting featured a wrap-up to consolidate learning and plan for maintenance. Project participation lasted 6 months. This structured approach allowed the program to be flexible yet consistent by embedding MBC within digital health infrastructures to support VHA’s mission to expand high-quality, data-driven care, particularly for rural and underserved Veterans.\u003c/p\u003e\u003cp\u003eThis QI project was determined to be non-human subjects research by the University of Iowa Institutional Review Board. Per VHA Handbook 1200.21 (Veterans Health Administration 2019), all VA authors of this manuscript attest that the activities that resulted in producing this manuscript were not conducted as part of a research project, but as part of a non-research evaluation conducted under the authority of the Office of Mental Health.\u003c/p\u003e\u003cp\u003eParticipants\u003c/p\u003e\u003cp\u003eParticipants were mental healthcare providers including psychologists and clinical social workers from a VAMC serving rural and highly rural Veterans in the Southcentral US. The service line was identified and recruited by the project lead (CT).\u003c/p\u003e\u003cp\u003ePre-Implementation Survey\u003c/p\u003e\u003cp\u003eAs part of the Discover phase, we conducted a pre-implementation survey with structured and open-ended questions. Demographic data were collected via closed ended questions. Qualitative data collected in the survey assessed provider opinion on benefits and drawbacks of MBC and education needs related to adding MBC to the provider’s clinical toolbox. Survey items were developed \u003cem\u003ede novo\u003c/em\u003e by the multidisciplinary project team to align with the objectives of the pre-implementation evaluation. The survey was collaboratively refined by team members representing clinical (CT, AH, MR) and implementation science (AH, LF) expertise to ensure relevance and face validity within the VHA context. Consistent with the rapid and iterative nature of QI work, the survey was not pilot tested prior to administration.\u003c/p\u003e\u003cp\u003eData was collected in August 2023. An electronic survey link, distributed via Qualtrics, was sent to 57 providers who were in attendance of the initial project meeting. Consent was implied via survey participation. The full survey is available as Appendix 1.\u003c/p\u003e\u003cp\u003eAnalysis\u003c/p\u003e\u003cp\u003eData obtained through Qualtrics was downloaded into Microsoft Excel and imported into SAS for data cleaning, management, and analysis. Descriptive statistics, including frequencies and summary measures, were used to analyze the characterological data of participating providers. All data were de-identified prior to sharing, and VHA secure data storage protocols were followed. All analyses were performed using SAS 9.4 \u003csup\u003e27\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eDescriptive statistics were used to analyze the demographic data of participating providers. Inductive thematic analysis \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e was applied by two members of the project team (AH, CT) to the qualitative data. Emergent themes were identified through the development of a codebook. To develop the codebooks, AH and CT together systematically reviewed 5 responses from each question, discussed key concepts, and agreed upon codes. The remaining responses were coded individually by CT and AH, iteratively developing the codebook until no new codes were identified and saturation was reached. A team meeting was held to achieve consensus when clarification was needed to address or revise codes.\u003c/p\u003e\u003cp\u003eData analyzed for this manuscript was utilized in an iterative feedback loop supporting the ongoing QI project. The timely analysis of this data was important to inform the Design phase.\u003c/p\u003e\u003cp\u003eThis manuscript was developed in accordance with the Standards for Quality Improvement Reporting Excellence guidelines \u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e (Appendix 2).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 46 staff members participated in the electronic survey, including psychologists (n\u0026thinsp;=\u0026thinsp;28), licensed clinical social workers (n\u0026thinsp;=\u0026thinsp;17), and a non-licensed social worker (n\u0026thinsp;=\u0026thinsp;1). Of the participants who shared information on their age, 54% were aged 40\u0026ndash;59, 37% were aged 25\u0026ndash;39, and 2% were 60+.\u003c/p\u003e \u003cp\u003eResults presented here are organized by perceived benefits, drawbacks, and educational needs related to MBC. The identified sub-themes provide insight into the nuances of implementing MBC and integration of the practice into clinical workflows. Quotes are reported verbatim (written).\u003c/p\u003e \u003cp\u003eBenefits\u003c/p\u003e \u003cp\u003eMany benefits of MBC were reported by participating providers and are organized across three subthemes: symptom awareness and monitoring, guiding clinical decision making, and facilitation of care delivery.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSymptom awareness and monitoring\u003c/h2\u003e \u003cp\u003eTwenty-six participants reported the benefit of symptom awareness and monitoring, including identification of symptoms, illumination of severity of symptoms, and the ability to easily track symptoms over time. Eleven participants reported that the assessments help identify symptoms that were not revealed during clinical interactions, with one provider sharing, \u0026ldquo;[MBC] \u003cem\u003eHelps to guide the treatment and open a forum for discussing specific symptoms that may otherwise go unnoticed\u0026rdquo;\u003c/em\u003e [ID007]. Another provider explained, \u003cem\u003e\u0026ldquo;It helps determine what symptoms may be more prevalent in a patient's situation. The Veterans are usually not aware of the degree of their depression for instance until they complete the PHQ-9\u0026rdquo;\u003c/em\u003e [ID0036]. Another noted, \u0026ldquo;\u003cem\u003e[MBC] helps you to be thorough and not miss symptoms in your assessment of current concerns\u0026rdquo;\u003c/em\u003e [ID0040].\u003c/p\u003e \u003cp\u003eInsight into symptom severity can be helpful in ongoing treatment planning, and as noted in the survey responses, Veterans may not be aware of the severity of their symptoms. One provider spoke to the benefit of quantifying symptom severity, expressing that MBC \u003cem\u003e\u0026ldquo;Puts symptom severity into an easier to understand number\u0026rdquo;\u003c/em\u003e [ID0028].\u003c/p\u003e \u003cp\u003eOne provider summed up the benefits of symptom awareness and the subsequent opportunity for guidance in treatment decision-making, stating, \u003cem\u003e\u0026ldquo;Significant benefits are diagnostic clarity, current snap shot of \"mental coordinates\", opportunity to discuss current factors, see improvement, make adjustments, understand their thought process and why they answer the way they did, provides feedback and other data such as habit and automatic thought process\" in responses if there are not any changes\u0026rdquo;\u003c/em\u003e [ID0035].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eGuiding Clinical Decision Making\u003c/h3\u003e\n\u003cp\u003eMBC can guide clinical decision-making through objective tracking of symptom change (or lack thereof), identifying progress toward care goals, and informing treatment and, ultimately, discharge planning.\u003c/p\u003e \u003cp\u003eProviders noted benefits of collecting assessment data, indicating that when first administered the assessment results give a baseline from which the response to treatment can be monitored. One provider shared, \u0026ldquo;\u003cem\u003eIt allows you to better understand the patient and gives you a baseline at which to measure the efficacy of treatment\u003c/em\u003e\u0026rdquo; [ID0041]. As data collection continues over the course of treatment, progress can be measured and viewed in a more objective manner. According to one provider, \u003cem\u003e\u0026ldquo;It helps provide additional data to patient and clinician's subjective experience and judgement to determine the effectiveness in treatment\u0026rdquo;\u003c/em\u003e [ID0033]. This objective understanding of the symptom change was noted as important by participating providers.\u003c/p\u003e \u003cp\u003eProviders spoke about how MBC\u0026rsquo;s provision of insights into nuanced symptom changes is valuable for treatment planning by helping to refocus goals and priorities and support patients\u0026rsquo; ability to identify and act on areas of concern. According to one provider, MBC \u003cem\u003e\u0026ldquo;provides a structure for involving the patient in a discussion regarding progress (or lack of)\u0026rdquo;\u003c/em\u003e [ID0002]. Other providers spoke about how MBC is good for identifying unmet needs, noting MBC helps with \u0026ldquo;\u003cem\u003etracking progress relative to goals [and to] identify sources of support needed that may not be being addressed by the current therapy\u0026rdquo;\u003c/em\u003e [ID0009], and \u003cem\u003e\u0026ldquo;For me and the patients to track their progress over time and see when therapy is making a difference and if not, where they may be stuck\u0026rdquo;\u003c/em\u003e [ID0010] .\u003c/p\u003e \u003cp\u003eRespondents reported how the psychoeducation component of MBC is a valuable tool in helping patients to better understand their diagnoses and symptom severity. \u003cem\u003e\u0026ldquo;Given the need for episodic care and the frequency with which Veterans present with complex, chronic problems, I think use of MBC can help both Veteran and provider feel clear and satisfied about progress in treatment. I work almost exclusively with patients with chronic issues because of my specialty and use of measures helps educate patients that fluctuations in symptoms do occur and help them think about quality of life beyond symptom focus\u0026rdquo; [ID0039].\u003c/em\u003e\u003c/p\u003e \u003cp\u003eOutside of the psychotherapy realm, one provider spoke about the value of MBC can be for psychotropic medication management. \u003cem\u003e\u0026ldquo;For veterans that are taking medications, if working, then I want to see their symptoms to be moderate to mild vs. moderate to severe. Then it can indicate a need to review medications to either increase dosage, maintain the dosage or even lower dosages at times\u0026rdquo;\u003c/em\u003e [ID0036].\u003c/p\u003e\n\u003ch3\u003eFacilitation of Care Delivery\u003c/h3\u003e\n\u003cp\u003eProviders conveyed that MBC facilitates engaging Veterans in treatment, supports rapport building, saves time and helps Veterans move toward acceptance of a clinical diagnosis. Helping Veterans feel more engaged in their own treatment was noted to be a benefit among many providers. Providers articulated important insights into their perceived value of MBC saying, \u003cem\u003e\u0026ldquo;completing the assessments during session strengthens partnership\u0026rdquo;\u003c/em\u003e [ID043], that MBC \u0026ldquo;\u003cem\u003e\u0026hellip; helps patients feel more involved in their own care\u0026rdquo;\u003c/em\u003e [ID0004], \u0026ldquo;\u003cem\u003evalidates a Veteran\u0026rsquo;s experience\u003c/em\u003e\u0026rdquo; [ID0011], \u0026ldquo;\u003cem\u003e[provides] better education about mental health conditions\u0026rdquo;\u003c/em\u003e [ID0012], and \u0026ldquo;\u003cem\u003ecan help people improve their self-monitoring and self-awareness of different symptoms and make links between symptoms and an overall diagnosis.\u0026rdquo;\u003c/em\u003e [ID0038].\u003c/p\u003e \u003cp\u003eTime was discussed in the report of benefits of MBC. MBC was reported as being a time-saver by some, but not all providers. One provider shared \u003cem\u003e\u0026ldquo;The biggest benefits of MBC are its use during intake assessments (almost as a \"short cut\" during these long assessments to help with time management)\u003c/em\u003e\u0026rdquo; [ID0006]. Time was also discussed in the context of being able to identify problem areas and make change right away, \u0026ldquo;\u003cem\u003eBeing able to track progress and act on areas of concern right away is invaluable. This is one of the other major pros of MBC\u003c/em\u003e\u0026rdquo; [ID0019].\u003c/p\u003e \u003cp\u003eIn addition to the clinical benefit of MBC, some providers described adjunctive benefits, specifically how MBC processes can act as a facilitator of care. One beneficial factor associated with successful uptake of clinical interventions is the ease with which individual technological systems (i.e. BHL Touch and VHA\u0026rsquo;s electronic health record (EHR)) work cohesively in support of the intervention. Some providers discussed the ease with which MBC can be integrated into video telehealth visits with one provider indicating that BHL touch provides an advantage in MBC, stating \u0026ldquo;\u003cem\u003eSince I started using BHL touch, I no longer feel I have a disadvantage to face-to-face providers (who can hand a form to a client, have them fill it out, then look it over later)\u0026rdquo;\u003c/em\u003e [ID0006]. Providers also pointed out the added benefit of the text message sent to collect symptom data acting as a secondary appointment reminder.\u003c/p\u003e \u003cp\u003eDrawbacks\u003c/p\u003e \u003cp\u003eProviders\u0026rsquo; reports on the drawbacks of MBC spanned three categories: assessment completion and self-report bias, structural barriers to provider engagement, and obstacles to evidence-based practice model adherence.\u003c/p\u003e\n\u003ch3\u003eAssessment Completion and Self-Report Bias\u003c/h3\u003e\n\u003cp\u003eProviders reported a drawback of MBC is that Veterans do not always complete the assessments, noting the circumstances in which this happens and a variety of possible reasons. Although reasons for non-participation are unique to each Veteran, providers cited a variety of perspectives as to why some Veterans may not complete assessments, including MBC not aligning with a Veteran\u0026rsquo;s goals, provider concerns about MBC having a negative impact on a Veteran, the possibility of self-report bias or response distortion, discouragement from stagnant scores or negative trends, and fear of impact on VA disability benefits. Incomplete assessments were reported to be expressly difficult in digital settings, with one provider describing how, \u003cem\u003e\u0026ldquo;when using during a telehealth visit- it can be hard to get compliance when asking them to do it prior to the session\u0026rdquo;\u003c/em\u003e [ID0026].\u003c/p\u003e \u003cp\u003eProviders noted that perhaps Veterans are inconsistent in completing assessments due to the Veteran\u0026rsquo;s perspective on the value of MBC. Some providers reported that the number of instruments used and the frequency of assessment places a burden on some Veterans, leading to MBC feeling \u0026ldquo;\u003cem\u003eclunky\u003c/em\u003e\u0026rdquo; and \u003cem\u003e\u0026ldquo;less personalized for patient care\u003c/em\u003e\u0026rdquo;. One provider shared \u003cem\u003e\u0026ldquo;Patients won't always respond or get frustrated with doing them.\u0026rdquo;\u003c/em\u003e [ID0046]. The value of MBC is not always realized immediately among Veteran patients, making it difficult to get \u003cem\u003e\u0026ldquo;Veteran buy in\u0026rdquo;\u003c/em\u003e to see the benefits of the treatment.\u003c/p\u003e \u003cp\u003eConcerns about negative psychological impacts on Veteran patients were communicated.\u003c/p\u003e \u003cp\u003eThe psychological impacts described included frustration, demoralization, discouragement, and anxiety provocation. One provider shared their experience that \u003cem\u003e\u0026ldquo;For some Veterans, it reinforces how poorly they are doing to fill the questions out week to week\u0026hellip;and it raises anxiety to fill out the questionnaire about how their anxiety is. There are cases where the measurement process really bothers Veterans. In those cases, I make adjustments rather than disqualify them from an evidence-based practice (assuming there are not other issues such as non-compliance from homework or high resistance to the structured session format)\u0026rdquo;\u003c/em\u003e [ID0006]. Further speculation on how MBC may impact the Veteran was conveyed by one respondent saying \u003cem\u003e\u0026ldquo;Some people communicate that seeing the numbers can elicit shame or discouragement that they are not improving, even though people in therapy tend to get worse before they get better\u0026rdquo;\u003c/em\u003e [ID0038].\u003c/p\u003e \u003cp\u003eProviders conveyed apprehension in accuracy of reported symptom data, due to self-reporting bias and reporting distortion. In some cases, inaccurate symptom data may be due to questions not being specific enough or fatigue in filling out the assessments. One provider expressed how MBC can create difficulties in the session, noting that issues arise \u0026ldquo;\u003cem\u003eWhen Veterans want to add to the questions because they are not specific enough or when Veterans elaborate too much on each question or get frustrated by questions (especially in longer assessments, like BASIS 24 and IMRS\u0026rdquo;\u003c/em\u003e [ID0022].\u003c/p\u003e \u003cp\u003eSome providers posited that response distortion may be influenced by a desire to seem better than they are or by a fear of reduction in benefits due to improvement. In these cases, providers indicated reticence to use MBC. Regarding reporting that may minimize appearance of symptom burden, one provider stated, \u0026ldquo;\u003cem\u003eSome veterans \u0026lsquo;fake good\u0026rsquo; and engage in more denial and minimization of symptom, so the numbers are reflective of what they report in sessions.\u0026rdquo;\u003c/em\u003e [ID0038].\u003c/p\u003e \u003cp\u003eFurther concern about self-report bias and response distortion was raised around the issue of suicidality. \u003cem\u003e\u0026ldquo;Patients learning how to respond to the measure to avoid having difficult conversations or hospitalization. For example, a veteran might learn that if they endorse having suicidal thoughts, they will get follow up questions that might lead to being hospitalized. Rather than saying, \u0026lsquo;I need to have this conversation,\u0026rsquo; they choose to deny having any suicidal thoughts. Alternately, some veterans tell us what they think we want to hear rather than how they actually feel because they want to be perceived as doing well in therapy or on a test (yes, scholastic assessment carries over for a long time!)\u0026rdquo;\u003c/em\u003e [ID0041].\u003c/p\u003e \u003cp\u003eAlternative ideas were offered to explain response distortion, with one provider sharing, \u0026ldquo;\u003cem\u003eSome patients who are therapy dependent react negatively to the positive outcomes. Some patients learn to answer negatively because they think that will keep them in therapy longer or look better for disability claims\u003c/em\u003e\u0026rdquo; [ID0043]. Leaning into the concerns about disability benefits, one provider responded, \u003cem\u003e\u0026ldquo;Possibly some Veterans will over-report out of concern that their service connection could be impacted (though I think this is a minority in actuality)\u0026rdquo; [ID0007.]\u003c/em\u003e Another stated, \u003cem\u003e\u0026ldquo;some Veterans are hesitant to answer honestly for fear of reduction in disability/benefits time\u0026rdquo; [ID0037].\u003c/em\u003e\u003c/p\u003e\n\u003ch3\u003eStructural barriers to provider engagement\u003c/h3\u003e\n\u003cp\u003eProviders cited structural barriers to using MBC, including concerns over asynchronous collection of time sensitive data (i.e. suicidality screening), functional and technical constraints of software used to support MBC, and overall time constraints.\u003c/p\u003e \u003cp\u003eThree instances were offered as examples of problems that arise due to asynchronous MBC. The first concerned timing and coordination with the EHR scheduling software. Providers noted that confounds arise when a Veteran completes their assessments ahead of time but then cancels or misses the appointment, as their assessment data then lacks an associated clinical visit and cannot be uploaded. The next concern about asynchronous assessment also related to cancellation but referenced the burden on the provider to keep track of what forms were sent out if a Veteran cancels and reschedules an appointment. Finally, results from an asynchronous assessment of symptoms may trigger the need for emergent follow up, which is problematic when follow up contact with the patient is unsuccessful. Clinician responses to a positive suicide screen gathered during asynchronous assessment may need to be dynamic, as the symptom measures are not always sensitive to acute versus chronic suicidal ideation, both of which can occur in Veterans accessing care. Providers conveyed the need to navigate legal and ethical clinical practice standards when working with individuals who report suicidality.\u003c/p\u003e \u003cp\u003eVarious functional and technical constraints were identified by participating providers. The library of assessments offered within BHL touch was noted by several providers to lack assessments that are needed for some patients. Some providers still utilized assessments that were not in BHL touch, with one respondent stating, \u003cem\u003e\u0026ldquo;I have been finding other ways to readily integrate other, more relevant measures into my practice that are not a part of the VA catalogue. But this does create issues with time in session, especially for Veterans who are being seen virtually and cannot fill out the measure in session\u0026rdquo;\u003c/em\u003e [ID0033].\u003c/p\u003e \u003cp\u003eOne provider described workflow inefficiencies when standardized assessments are not available through BHL Touch, noting that alternate methods (e.g., email or patient portal) often reduce response rates and require using valuable session time to complete measures that could otherwise be done independently.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eThere are times when something is not on BHL touch, and in those cases, I have to e-mail or MHV\u003c/em\u003e [My HealthEVet, patient portal] \u003cem\u003ethe info (which then I typically don't get anything back) or I have to complete the assessment verbally (which takes session time I prefer to spend doing something non-standardized). For example, I am a provider in an OCD study which asks for the Y-BOCS to be filled out 1x/2 sessions. I have to e-mail rather than have a text sent, and the Veteran tends to fill it out in session with me rather than getting it done ahead of time. When I use BHL touch for the same Veteran to complete a PHQ and PCL, they typically get it done outside of session\u003c/em\u003e [ID0006].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eTechnical issues reported were related to software malfunctions, accessibility (if a Veteran\u0026rsquo;s device does not allow them to see the provider or screen during a video visit), and the impact of technical failures on the provider and patient relationship. One provider expressed, \u003cem\u003e\u0026ldquo;When it doesn't work, it can be very frustrating (this can be especially important during an intake assessment when there may be high suspicion or nervousness coming into the appt)\u0026rdquo;\u003c/em\u003e [ID0006].\u003c/p\u003e \u003cp\u003eConcern about technological proficiency among Veterans was reported as a barrier to MBC. Some providers reported a lack of confidence in their Veteran-patients\u0026rsquo; ability to access and navigate the technology used by VHA in MBC (i.e. BHL Touch). On the other hand, one provider spoke about how providers need to be able to respond to Veteran\u0026rsquo;s preferences, \u0026ldquo;i\u003cem\u003en this day and age the patients dictate the level of technology they are comfortable with yet as providers we need to be familiar with all options\u0026rdquo;\u003c/em\u003e [ID0036].\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eTime as a Barrier\u003c/h2\u003e \u003cp\u003eIssues around time as a barrier to uptake of MBC were reported among numerous respondents. When queried about the potential drawbacks of MBC, some providers simply responded with one word, \u0026ldquo;\u003cem\u003etime\u003c/em\u003e\u0026rdquo;. Others shared more nuanced perspectives, noting that the time required to complete surveys during sessions and to review the data for discussion and treatment planning impacted adoption. One provider explained, \u0026ldquo;\u003cem\u003ethe biggest problem I have is time required if the assessments are completed in session. BHL is a great tool, but Veteran compliance varies\u0026rdquo;\u003c/em\u003e [ID0002]. Time as a barrier crossed over with reported Veteran engagement issues, with one provider noting, \u0026ldquo;\u003cem\u003eit does take session time and often patients aren\u0026rsquo;t as interested in that as other things, so it feels like a struggle to make them do MBC stuff\u0026rdquo;\u003c/em\u003e [ID0039].\u003c/p\u003e \u003cp\u003eAnother provider suggested that time constraints are related to reviewing and planning, stating a barrier to adoption is \u0026ldquo;\u003cem\u003eneeding the time to review the assessments. Needing the time to adjust the course of overall treatment when assessments suggest so\u0026rdquo;\u003c/em\u003e [ID0024].\u003c/p\u003e \u003cp\u003eThe concern for time was not universal, with one provider stating \u003cem\u003e\u0026ldquo;I don\u0026rsquo;t know of any drawbacks. Time is really not an issue when you get used to it\u0026rdquo; [ID0019].\u003c/em\u003e Despite that provider\u0026rsquo;s enthusiasm, the sentiment was not universally shared and participating providers offered important insights into the drawbacks of MBC that impact its usability in clinical care.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMeasure Validity and Therapeutic Value\u003c/h3\u003e\n\u003cp\u003eProvider reports on barriers to fidelity to MBC as an evidence-based practice included not always understanding the therapeutic value of MBC, the predictive validity of specific measures and their sensitivity to change over the course of treatment, and how to respond clinically when Veteran\u0026rsquo;s scores did not indicate clinical improvement. For example, providers relayed their perception that scores are not necessarily always accurate, that \u0026ldquo;\u003cem\u003emeasures don\u0026rsquo;t always accurately capture change\u003c/em\u003e\u0026rdquo; [ID0020], and that since the assessments are symptom focused, MBC \u0026ldquo;\u003cem\u003edoes not always capture important qualitative elements of change (e.g. sense of confidence, improvement in relationships, sense of social connectedness, movement toward personal life goals like applying for jobs or school). Some therapy goals may be more interpersonal and less symptom focused, or some symptoms may be expected to demonstrate less overt change that can be tracked easily, such as personality disorders or SMI [serious mental illness]\u0026rdquo;\u003c/em\u003e [ID0041].\u003c/p\u003e \u003cp\u003eOne provider indicated that sometimes assessment scores do not match the lived experiences of Veterans, stating \u0026ldquo;\u003cem\u003ealthough the scores can be helpful on eliciting more discussion about certain symptoms I don\u0026rsquo;t think they are necessarily very accurate for various reasons; i.e. the Veteran\u0026rsquo;s perception of their score upon further discussion does not always match what one would assume if just looking at numbers\u0026rdquo;\u003c/em\u003e [ID0026].\u003c/p\u003e \u003cp\u003eBeyond concerns about item or total score validity, therapeutic value of MBC processes was also explored by participating providers. Specifically, assessment cadence (e.g., how frequently the assessments are sent out) raised two concerns among providers in two ways: that weekly assessments posed an undue burden on Veterans and that changes in symptoms were less noticeable when measures were obtained more frequently.\u003c/p\u003e\n\u003ch3\u003eStagnation or Decline\u003c/h3\u003e\n\u003cp\u003eProviders expressed concerns about the potential for challenges navigating clinical care, for the clinician or the Veteran, when a Veteran\u0026rsquo;s symptom scores lack of evidence of clinical improvement. One provider stated that their perceived negative impact on the Veteran hindered their use of MBC because of the potential drawback due to demoralization, sharing \u003cem\u003e\u0026ldquo;Demoralization if their scores don\u0026rsquo;t change. If there are structural reasons the treatment will need to end (i.e., come to end of protocol, etc.) and the scores are not improved, it makes it hard for the clinician to handle that clinically. My interest in it at a program/team/clinic level is hard because most people don\u0026rsquo;t use it. So it\u0026rsquo;s hard to get the data I want from it. And then over time, it impacts my own individual motivation to use it\u0026rdquo;\u003c/em\u003e [ID0039].\u003c/p\u003e \u003cp\u003eSome providers shared their concerns about their performance evaluation based on patient outcomes. One provider reported, \u0026ldquo;\u003cem\u003eI have heard providers express concern that their clinical performance/efficacy will be judged according to the Veterans' MBC results\u0026rdquo;\u003c/em\u003e [ID0007].\u003c/p\u003e \u003cp\u003eAnother shared, \u003cem\u003e\u0026ldquo;They are not the end all be all. There are a variety of reasons why someone may score a certain way and that needs to be discussed and taken into account. At times it feels like VA places too much emphasis on MBC being the main driving indicator of therapy success\u0026rdquo;\u003c/em\u003e [ID0011].\u003c/p\u003e \u003cp\u003eEducational Needs\u003c/p\u003e \u003cp\u003eProviders requested training in psychometric properties of assessments to inform selection and interpretation, how to talk to Veterans about the Collect, Share, and Act components of MBC, and workflow and integration into their own practice. They asked for small-group or step-by-step training, workflow guidelines, and a full assessment directory. Respondents spoke about the need for good training in MBC, with one provider sharing her belief that when MBC is used by providers who are poorly trained, it leads to poor patient experience.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eAssessments selection and interpretation\u003c/h2\u003e \u003cp\u003eTwo overarching educational needs around assessment selection and interpretation were identified: 1) awareness and understanding of assessments and psychometric properties to inform selection and interpretation and 2) knowing which assessments best capture symptom burden related to specific diagnoses.\u003c/p\u003e \u003cp\u003eProviders broadly indicated a need for a better understanding of what is available, with one provider suggesting the desire for a \u0026ldquo;directory of measures\u0026rdquo;. One provider asked for a \u0026ldquo;\u003cem\u003eresource including what other providers use when treating a specific condition and why\u0026rdquo;\u003c/em\u003e [ID0001]. Another provider spoke to the gap in available assessments, reporting, \u003cem\u003e\u0026ldquo;I am having problems finding a good assessment tool to use for anger management. Most published measures regarding anger are \u0026lsquo;trait\u0026rsquo; measures rather than a \u0026lsquo;state\u0026rsquo; measure and not that useful for repeat assessment\u0026rdquo;\u003c/em\u003e [ID0002].\u003c/p\u003e \u003cp\u003eBeyond awareness of what is available, providers shared that to feel more confident in using MBC, they need to better understand psychometric properties of the assessments available on BHL touch and what constitutes clinically meaningful change in scores. Several providers emphasized the need for additional guidance on how to interpret assessment results and apply them meaningfully in treatment, noting that further training would help them use these tools more effectively. Specifically, how they as a provider can translate scores into treatment planning. One provider noted that a barrier to adherence was \u0026ldquo;\u003cem\u003eNot fully understanding the meaning gained from some assessments\u003c/em\u003e\u0026rdquo; [ID0024]. Others described what would help them, sharing they would like \u003cem\u003e\u0026ldquo;Education on the specific meaning/interpretation of the assessments and how they could inform the treatment and give meaning to Veterans for the major assessments\u003c/em\u003e\u0026rdquo; [ID0024], and \u0026ldquo;\u003cem\u003eTraining to better help the providers to understand the results of the tools and how to utilize them effectively in treatment\u0026rdquo;\u003c/em\u003e [ID0042]. One provider reported a detailed and insightful educational need related to understanding the minimal important difference for the measures, stating that education would be helpful on\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;What are statistically significant changes in total score for some of the more common measures (PHQ9, GAD, PCL, CESD). I.e. I think I've heard 5 pts for phq9 but I am not sure so this is just a fake example: Say you are working with a pt with a depression goal and although your pt's total score improvement did not trend at/below minimal depression, but say they had a (greater than) or =\u0026thinsp;5 pt reduction in total score from 18 to 12 and this is deemed statistically significant for this measure meaning that they likely saw a meaningful change and this is still considered a successful episode of care...\u0026rdquo;\u003c/em\u003e [ID0045].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eA need for nuanced education around selection and interpretation of assessments that best measure symptoms associated with particular mental health conditions or patient circumstances was reported. Personality disorders were identified as challenging diagnoses for utilizing MBC, as some providers indicated it is difficult to find assessments that are time-sensitive, as many assessments of personality disorders are lengthy, and that are sensitive to the discrete symptom change that is anticipated in treatment of personality disorders.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eProvider-delivered psychoeducation\u003c/h2\u003e \u003cp\u003eProviders consistently asked for education on how to discuss MBC with Veterans. Specifically, providers want to know how to explain the meanings and interpretations of the assessments, how to inform Veterans on the impact of their results on the treatment options, how to discuss symptom changes (or lack thereof), and how to make discussing MBC more relatable to the Veteran patient., One provider responded, \u0026ldquo;\u003cem\u003eHow to show results of assessments over time over VVC\u003c/em\u003e [VHA\u0026rsquo;s Video Chat], \u003cem\u003ejust some discussion about helpful ways to talk about use of measurements with Veterans, and education about how to best use some of the measures (info about the purpose, data about reliability/validity)\u0026rdquo;\u003c/em\u003e [ID0032].\u003c/p\u003e \u003cp\u003eSome providers sought nuanced education on specific topics, such as how to discuss scores that do not align with patients\u0026rsquo; narrative reports or how to address changes over time, effective implementation when caring for patients presenting with therapy blocking behaviors, or who may be experiencing higher levels of distress in an outpatient setting. One provider noted the need for education related to caring for patients with particular diagnoses, sharing \u0026ldquo;\u003cem\u003eMBC troubleshooting for certain presenting concerns -- for example in the DBT [Dialectical Behavioral Therapy] team, where treatment can last for a year, we don't have great options for MBC for patients with BPD [Borderline Personality Disorder]- we have tried a range of them like the DERS [Difficulty in Emotion Regulation Scale], BSL-23 [Borderline Symptom List 23]- none of them capture what we want to track for individual patients and other measures are not available on MHA [Mental Health Assistant] /BHL/VHA system. Other personality disorders as well - not a lot of brief options for tracking change in the first place (generally extremely lengthy!), and PDs [Personality Disorders] may not be expected to show significant changes in discrete symptom count\u0026rdquo; [\u003c/em\u003eID0040].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eWorkflow and Integration into Clinical Practice\u003c/h2\u003e \u003cp\u003eProviders reported broad educational needs related to workflow, varying from broad requests of \u0026ldquo;\u003cem\u003eanything to streamline the workflow\u003c/em\u003e\u0026rdquo; [ID0007] to a \u0026ldquo;\u003cem\u003estep-by-step process\u003c/em\u003e\u0026rdquo; [ID0028]. Education needs around the technology varied. Some providers reported a need for fundamental training on the use of BHL Touch software, such as how to log in, send the surveys to the Veterans, and integrate the assessments into the EHR. One provider requested education on how to work with BHL to add assessments to the library, stating \u0026ldquo;\u003cem\u003eGetting more measures built into the programs. I have a niche measure for my ADHD patients that others might find very insightful, but it's not on any of the MBC programs. I have to deliver it via WebEx Poll any time I want to use it, which is very cumbersome and time consuming, but worth it\u0026rdquo;\u003c/em\u003e [ID0041].\u003c/p\u003e \u003cp\u003eAnother issue providers reported needing help navigating is more than one licensed independent practitioner (LIP) may be using MBC with the same patient, with one provider asking for information on \u0026ldquo;\u003cem\u003ewhich LIPs should be administering them\u003c/em\u003e\u0026rdquo; [ID0036], speaking to the nuances of engaging in MBC in a multidisciplinary setting.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis qualitative inquiry to assess provider perceptions of MBC to inform development of a digital MBC workflow in a tele-health setting revealed nuanced views of its clinical utility, barriers to adoption, and areas for provider training\u0026mdash;directly addressing the initial research aim. Findings demonstrate the intersection of digital health implementation and behavioral healthcare delivery, highlight the nuanced factors influencing tMBC adoption in VHA telehealth settings, and underscore how workflow integration and user-centered design remain critical determinants for successful adoption of digital tools in telehealth environments.\u003c/p\u003e \u003cp\u003eIn descriptions of the benefits of MBC, providers recognized its potential to enhance symptom awareness and monitoring, support treatment planning, and facilitate patient engagement in therapy. Regarding barriers to uptake of tMBC, they shared persistent barriers that limited routine use such as time constraints, inconsistent Veteran participation, functionality of digital tools, and challenges in interpreting and applying results. Educational needs reflected barriers identified, with requests for training centered around psychometric proprieties of measures, effective communication strategies with Veterans, and guidance on integrating digital tools into workflows.\u003c/p\u003e \u003cp\u003eConsistent with prior implementation studies, providers emphasized a need for structured guidance on communicating results to Veterans\u0026mdash;a gap that may be addressed through MBC-specific psychoeducation tools. Providers requested language that could specifically be used in clinical encounters to help a Veterans understand the clinical intervention. Based on this feedback, it was determined that providers need training and ongoing clinical support on how to provide psychoeducation on MBC that effectively educates the Veteran patients on all components of this clinical intervention, ranging from risks and benefits of the treatment method to sharing results that provide insight into the illness and meaningfully impact treatment decisions. Psychoeducation is a vital element of widely used psychotherapeutic models like Cognitive Behavioral Therapy\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e, Dialectal Behavioral Therapy\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e, Acceptance and Commitment Therapy \u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e, and Psychodynamic Psychotherapy \u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e. Mental health providers who use these models during therapeutic interventions have been taught how to provide psychoeducation in the context of that model through manuals, training, certification courses, etc. However, there is a gap in the literature regarding how to provide psychoeducation specific to the MBC model \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e. Similar challenges have been reported in other disciplines- such as physical therapy \u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e, occupational therapy, and physiotherapy \u003csup\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e-that also integrate assessment and measurement into routine clinical care.\u003c/p\u003e \u003cp\u003eConcerns about how to manage suicidality disclosures highlight the need for standardized communication protocols and informed consent procedures within digital MBC workflows along with ongoing clinical support for individual cases. Across the United States, organizations vary widely in their approaches to responding to a positive suicide screen, ranging from follow up phone calls to welfare checks to mandatory hospitalizations, and other forms of intervention. Across VHA, providers using MBC work on interdisciplinary teams, with each discipline having their own best practices for responding to positive suicide screens whilst working together to ensure overall best care and safety of a Veteran. In discussing the measures selected for a patient, providers have an opportunity to educate the Veteran about the implications of a positive responses on suicide-related items.\u003c/p\u003e \u003cp\u003eSuccessful adoption of MBC must include education and an emphasis on MBC\u0026rsquo;s central tenant that clinical symptom rating and other assessment scales are tools to be used in concert with history-taking and clinical judgment, which is always paramount for an effective treatment approach. Furthermore, selection of appropriate assessment tools requires knowledge of the psychometric properties of the individual tools in the context of clinical assessment and clinical judgement. This can be an important factor when providers are considering measures with the potential to capture self-report bias, such as over or under-reporting \u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e, which could confound effective treatment. Whether an assessment score stagnates, worsens, or improves, clinicians need reassurance that there is always a need for interpretation of the measurement data in the context of the overarching clinical assessment, including the indications for further inquiry, the use of collateral informants, consultation with other colleagues, and consideration of the appropriateness or validity of the scale/measure for that specific patient\u0026rsquo;s condition. For example, changes in sleep patterns and the absence of depressive phenomena on the PHQ-9 could reflect cycling from a depressed to a manic state or cognitive decline could impact the ability of a patient to respond using a self-report scale.\u003c/p\u003e \u003cp\u003eImplications\u003c/p\u003e \u003cp\u003eThis study contributes to the growing field of digital health by demonstrating how technology-enabled measurement and feedback systems can enhance the reach and quality of mental health services. Tailored, discipline-specific training modules addressing psychometrics of self-report assessment tools, digital workflow, and communication strategies could enhance provider confidence and uptake. VHA\u0026rsquo;s infrastructure and data capacity make it a powerful setting for MBC growth, yet the success of MBC depends on equipping providers with the knowledge and confidence to select, use, and apply assessment tools meaningfully. Providers\u0026rsquo; experiences underscore how digital tools, such as BHL Touch and VHA Video Connect, serve as digital health enablers, that improve coordination, data flow, and patient engagement\u0026mdash;core dimensions of digital healthcare transformation. Embedding MBC within digital health infrastructures supports the VHA\u0026rsquo;s mission to expand access to high-quality, data-driven care, particularly for rural and underserved Veterans.\u003c/p\u003e \u003cp\u003eStrengths and Limitations\u003c/p\u003e \u003cp\u003eThis study has several strengths and limitations that should be considered when interpreting its findings. A key strength lies in its timely discovery of provider perspectives to inform the design and build phases in a quality improvement initiative within VHA. By capturing provider insights early, the data directly informed subsequent design and workflow adaptations, exemplifying a learning health system approach\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe sample included two mental health disciplines serving rural and highly rural Veterans across a large geographic area, offering a rich view of barriers and facilitators to implementing MBC in virtual settings. The use of inductive thematic analysis and multiple coders enhanced analytic rigor and credibility.\u003c/p\u003e \u003cp\u003eNevertheless, the study has limitations. Qualitative data were collected through open-ended survey responses rather than in-depth interviews or focus groups. Although this approach facilitated participation from a geographically dispersed provider group, it limited opportunities for follow-up probing and contextual clarification. Responses may be subject to self-selection and social desirability bias, as providers who were more engaged or favorable toward MBC may have been more likely to participate or to emphasize positive aspects of implementation. The survey was developed de novo and was not pilot-tested or validated, which may influence content comprehensiveness and construct coverage. Finally, the analysis reflects perspectives from providers within one VHA mental health service line and may not be generalizable to all VHA settings or non-VHA health systems.\u003c/p\u003e \u003cp\u003eAs this work represents the Discover phase of a quality improvement project, findings capture anticipated rather than observed implementation challenges and outcomes.\u003c/p\u003e \u003cp\u003eDespite these limitations, the results provide valuable early insights into provider readiness, perceived barriers, and educational needs that directly informed subsequent phases of MBC implementation within virtual mental health care delivery.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe results detailed in this manuscript informed the development of an implementation strategy that identified core clinical, technical, and administrative requirements necessary for effective, digitally delivered MBC, while allowing for variability across settings and underlying information technology platforms. For this QI project, providers\u0026rsquo; nuanced perceptions of benefits, drawbacks, and educational needs was paramount to the Design, Build, and Test phases of the project.\u003c/p\u003e \u003cp\u003eThis project underscores that while VHA is well-positioned to lead in MBC implementation, adoption is not automatic. A structured, provider-informed, and Veteran-sensitive approach is essential. By educating providers on psychometric properties of assessments and integrating digital tools like BHL Touch with workflows, training, and communication strategies, MBC can become a routine, meaningful part of digital mental health care delivery in the VHA and beyond. As digital health ecosystems continue to evolve, integrating MBC into telehealth delivery offers a scalable pathway to improving mental health care access, personalization, and continuity for diverse populations.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBASIS-24\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Behavior and Symptom Identification Scale\u0026ndash;24\u003c/p\u003e\n\u003cp\u003eBHL Touch \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Behavioral Health Lab Touch\u003c/p\u003e\n\u003cp\u003eBPD \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp;Borderline Personality Disorder\u003c/p\u003e\n\u003cp\u003eCBOC \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Community-Based Outpatient Clinic\u003c/p\u003e\n\u003cp\u003eCES-D\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Center for Epidemiologic Studies Depression Scale\u003c/p\u003e\n\u003cp\u003eDBT \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp;Dialectical Behavioral Therapy\u003c/p\u003e\n\u003cp\u003eDERS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Difficulties in Emotion Regulation Scale\u003c/p\u003e\n\u003cp\u003eEHR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Electronic Health Record\u003c/p\u003e\n\u003cp\u003eLIP \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Licensed Independent Practitioner\u003c/p\u003e\n\u003cp\u003eMBC \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp;Measurement-Based Care\u003c/p\u003e\n\u003cp\u003eMHV \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp;My HealtheVet\u003c/p\u003e\n\u003cp\u003ePCL \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;PTSD Checklist (Version 5)\u003c/p\u003e\n\u003cp\u003ePE \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp;Prolonged Exposure Therapy\u003c/p\u003e\n\u003cp\u003ePHQ-9 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp;Patient Health Questionnaire-9\u003c/p\u003e\n\u003cp\u003ePTSD \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Post-Traumatic Stress Disorder\u003c/p\u003e\n\u003cp\u003eQI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp;Quality Improvement\u003c/p\u003e\n\u003cp\u003eQUERI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp;Quality Enhancement Research Initiative\u003c/p\u003e\n\u003cp\u003eSAS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Statistical Analysis System\u003c/p\u003e\n\u003cp\u003eSMI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp;Serious Mental Illness\u003c/p\u003e\n\u003cp\u003etMBC\u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Telehealth-delivered Measurement Based Care\u003c/p\u003e\n\u003cp\u003eVAMC \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Veterans Affairs Medical Center\u003c/p\u003e\n\u003cp\u003eVHA \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Veterans Health Administration\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVVC \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; VA Video Connect\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e This project was conducted in accordance with the principles of the Declaration of Helsinki. The project procedures were reviewed by the University of Iowa Institutional Review Board (IRB #202009601), were determined to constitute non\u0026ndash;human subjects research and, as such, the need for informed consent to participate was waived. The Iowa City Veterans Affairs Research and Development Committee reviewed and approved the project.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eConsent for publication\u003c/h2\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eOur quality improvement (QI) project \u003cem\u003e\u0026ldquo;Virtual Care QUERI Program: Implementation of Technology Facilitated Evidence Based Practices to Improve Access to High Quality Care for Rural Veterans\u003c/em\u003e\u0026rdquo; (project number QUE 20\u0026thinsp;\u0026minus;\u0026thinsp;007) was funded by VA\u0026rsquo;s Quality Enhancement Research Initiative.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConceptualization \u0026amp;amp; Design: CT, JF, JLData curation: CT, NS, LF, AH, CH, LMAnalysis: KM, CT, AHFunding acquisition: CT, JFInvestigation: CT, NS, LF, AHMethodology: CT, AHProject administration: CT, NS, LF, AH, CH, LMResources: CTSupervision: CTValidation: CT, NS, LF, AHWriting​: AH, CT, KMWriting \u0026ndash; review \u0026amp;amp; editing:​ AH, LF, NS, CH, LM, KM, JL, JF, CT\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eNot Applicable\u003c/p\u003e \u003cp\u003eArtificial Intelligence\u003c/p\u003e \u003cp\u003ePortions of this manuscript were edited with the assistance of an artificial intelligence (AI) tool, ChatGPT (GPT-5, OpenAI). Outputs underwent rigorous human review to ensure accuracy, clarity, and appropriateness for scholarly publication. Consistent with International Committee of Medical Journal Editors recommendations \u003csup\u003e42\u003c/sup\u003e, the authors maintained full responsibility for the content and interpretation of the manuscript. The use of AI was limited to language refinement and did not involve interpretation of study data.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe qualitative data generated and analyzed during the current study is not publicly available in accordance with VA policy governing research data collected within the VA system. Although the study did not involve Veteran patients, the data consists of surveys completed by VA mental health providers and include potentially sensitive information about VA clinical practices, organizational processes, and internal operations. Per VA policy on research data management and access, such data may not be shared outside the VA without explicit authorization and a formal Data Use Agreement approved by the local VA Research \u0026amp; Development Committee.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFriedman C, Rubin J, Brown J, Buntin M, Corn M, Etheredge L, Gunter C, Musen M, Platt R, Stead W, Sullivan K. Toward a science of learning systems: a research agenda for the high-functioning Learning Health System. J Am Med Inform Assoc. 2015;22(1):43\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFortney JC, Un\u0026uuml;tzer J, Wrenn G, Pyne JM, Smith GR, Schoenbaum M, Harbin HT. A tipping point for measurement-based care. Psychiatric Serv. 2017;68(2):179\u0026ndash;88.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZimmerman M, McGlinchey JB. 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InManual for the Standard for Clinicians\u0026rsquo; Interview in Psychiatry (SCIP) A New Assessment Tool for Measurement-Based Care (MBC) and Personalized Medicine in Psychiatry (PMP) 2022 Jul 16 (pp. 193\u0026ndash;204). Cham: Springer International Publishing.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaley SM, Fragala-Pinkham MA. Interpreting change scores of tests and measures used in physical therapy. Phys Ther. 2006;86(5):735\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFawcett AL. Principles of assessment and outcome measurement for occupational therapists and physiotherapists: theory, skills and application. Volume 15. Wiley; 2013 Mar.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRosenfeld B, Green D, Pivovarova E, Dole T, Zapf P. What to do with contradictory data? Approaches to the integration of multiple malingering measures. Int J Forensic Mental Health. 2010;9(2):63\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInternational Committee of Medical Journal Editors. Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.icmje.org/recommendations/\u003c/span\u003e\u003cspan address=\"http://www.icmje.org/recommendations/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. 2024. Accessed October 27, 2025.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Measurement-Based Care, Veterans Health Administration, Veteran mental health, rural healthcare, tele-mental health, digital workflow, quality improvement, telehealth, digital mental health, provider training","lastPublishedDoi":"10.21203/rs.3.rs-8406956/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8406956/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eMeasurement-Based Care (MBC) uses repeated standardized psychological assessments to monitor treatment progress and guide clinical decision-making. Although MBC improves outcomes when results are discussed collaboratively, adoption across the Veterans Health Administration (VHA) remains below 50%, particularly in virtual and rural settings. This pre-implementation evaluation explored provider perspectives to inform development of a digital MBC workflow for rural tele-mental health settings.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eUsing the Alacrity Center\u0026rsquo;s Discover, Design, Build, and Test model and User Centered Design, we conducted a pre-implementation survey of mental health providers at a VHA Medical Center providing care to rural and highly rural Veterans in Southcentral United States. Providers represented disciplines of psychology and social work. The survey contained structured and open-ended questions assessing prior MBC use, perceived benefits and drawbacks, and educational needs. Qualitative data underwent inductive thematic analysis by two independent coders using consensus review to identify emergent themes.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eForty-six providers identified three key benefits of MBC: enhanced symptom awareness and monitoring, support for data-informed treatment planning, and facilitation of patient engagement and shared decision-making. Reported barriers included time constraints, inconsistent Veteran participation, functionality of digital tools, and challenges in interpreting and integrating results. Providers also expressed concern over the accuracy of self-report measures and potential negative psychological effects of repeated symptom tracking. Educational needs clustered around three domains: (1) psychometric understanding of measures, (2) effective communication of results with Veterans, and (3) practical guidance on integrating digital tools into workflow. Illustrative quotes are presented verbatim.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e \u003cp\u003eProvider feedback underscores that successful MBC implementation in digital mental health requires not only technological infrastructure but also targeted provider education and psychoeducational tools. Training should emphasize interpretation of assessment data, patient-centered communication, and safe, ethical management of sensitive results. Embedding MBC within a structured digital workflow supported by provider-informed design can enhance engagement, streamline care, and align with VA\u0026rsquo;s goal to expand high-quality, data-driven mental health services for rural Veterans. Given the quality improvement context, findings should be interpreted as context-specific insights used to shape local implementation rather than generalizable evidence.\u003c/p\u003e","manuscriptTitle":"Implementing Measurement-Based Care in Virtual Mental Health Services for Rural Veterans: Provider Insights from a Pre- Implementation Evaluation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-12 03:43:46","doi":"10.21203/rs.3.rs-8406956/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-16T09:50:34+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-10T03:51:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-09T20:18:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-09T14:24:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"337717622038051587064810728430218277305","date":"2026-01-30T02:58:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"302751987324978203210807483708948478014","date":"2026-01-28T21:06:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"268694854919083278957962467973736305953","date":"2026-01-28T02:55:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"46320025247707032480459288996011309040","date":"2026-01-26T13:58:09+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-24T19:51:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"183244454557528083524900960339678861701","date":"2026-01-23T15:58:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"323774003221348720654813610074631668280","date":"2026-01-07T20:29:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"180794659041972506744212197549287231041","date":"2026-01-06T16:56:52+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-06T12:12:27+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-06T12:09:04+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-06T11:03:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-05T19:46:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2026-01-05T19:40:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"58352ca7-617a-44b2-8f52-f8e4fe811775","owner":[],"postedDate":"January 12th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-07T16:04:41+00:00","versionOfRecord":{"articleIdentity":"rs-8406956","link":"https://doi.org/10.1186/s12913-026-14490-6","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2026-04-03 15:57:43","publishedOnDateReadable":"April 3rd, 2026"},"versionCreatedAt":"2026-01-12 03:43:46","video":"","vorDoi":"10.1186/s12913-026-14490-6","vorDoiUrl":"https://doi.org/10.1186/s12913-026-14490-6","workflowStages":[]},"version":"v1","identity":"rs-8406956","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8406956","identity":"rs-8406956","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}