Improving Patient-centered Care Using an Inventory
Improving Patient-centered Care Using an Inventory
This study will use a multi-phase mixed-methods approach to develop and test a patient
 inventory to facilitate patient-centered care delivery. In Phase I the investigators will
 identify which factors should be considered for inclusion in the patient inventory. This will
 involve qualitative data collection with providers and patients using interviews and focus
 groups, respectively; and developing a question repository. The interviews and focus groups
 will take place at the six study sites: Hines VA Hospital and two Community Based Outpatient
 Clinics(CBOCs) in LaSalle, Illinois (IL) and Kankakee, IL; Jesse Brown VA Medical Center; and
 two CBOCs in Crown Point, IN; and Chicago Heights, IL. The question repository will involve a
 research assistant (RA) performing a literature review to gather items related to areas of
 patient context.

 Phase II will develop and test an item inventory using a Delphi panel - a panel of
 stakeholders including Veteran representatives, VA providers, researchers and representatives
 from the investigators' operations partners. The panel of at least 14 respondents will
 develop a questionnaire through three rounds of email exchanges ranking the list of items to
 be included in the patient inventory. Once the patient inventory is finalized, it will be
 integrated into an iPad application for patient use.

 In Phase III the investigators will test the patient inventory in a randomized trial.

 The investigators will conduct a randomized trial of the patient inventory to a control
 condition (e.g., healthy living video) to assess whether use of the inventory results in care
 that is more patient-centered and decisions that are more collaborative. Eligible
 participants will be identified and recruited from the Patient Aligned Care Team (PACT)
 clinics at Hines and Jess Brown VA facilities. Patients will be randomly assigned to either
 complete the patient inventory on the iPad or watch a health video on the iPad. Patients in
 the Intervention group will give a copy of the summary of the inventory to their provider.
 Both groups will be asked to carry a concealed tape recorder during their visit. Following
 the visit, patients in both groups will complete a set of questionnaires about the encounter
 including the CARE and CCM. The recordings will be analyzed by the team using a coding system
 developed in a previous Health Services Research and Development (HSR&D) study to see if the
 use of the patient inventory facilitated patient-centered care during the encounter. A second
 coding scheme, the Informed Decision Making (IDM) will also be applied to examine
 collaborative decision making.
Research Design and Methods: This study will utilize a multi-phase mixed-methods approach to
 develop and test a patient inventory to facilitate patient-centered care delivery. In Phase I
 the investigators will identify which factors should be considered for inclusion in the
 patient inventory. This will involve interviews and focus groups with providers and patients,
 respectively; and a review of the relevant literature. In Phase II the investigators will
 develop and test an inventory using a Delphi panel and assembling a questionnaire repository.
 In Phase III the investigators will conduct a randomized trial comparing the patient
 inventory to a control condition (e.g., healthy living video) to assess whether use of the
 inventory results in care that is more patient-centered and decisions that are more
 collaborative.

 Phase I: To identify patient contextual factors and preferences, and patients' experiences,
 awareness, resources, and willingness to use technology for care delivery, the investigators
 will conduct focus groups with patients at 2 facilities and 4 CBOCs in Veterans Integrated
 Service Network 12 (VISN 12) representing urban and rural settings and a mix of
 sociodemographic characteristics.

 In order to capture the perspective of Veterans who live in more rural areas and who may
 represent a broader range of socio-demographic characteristics, the investigators will
 conduct focus groups at four CBOCs associated with the medical facilities that represent
 urban/rural and ethnic diversity.

 The investigators plan to recruit both patients who have received care through technology
 (e.g., home telehealth (HT), CVT) and those who have had little or no experience with care
 delivered through technology. The investigators will conduct separate focus groups with
 patients who have received care through technology and those who have not used technology for
 health care. Focus group discussions will be transcribed verbatim and analyzed using constant
 comparative techniques to code the data thematically. This information will serve as the
 foundation for developing the inventory.

 A total of 8-12 focus groups will be conducted with 5-8 Veteran participants per group (n=40
 to 96 patients). The investigators will conduct 2 focus groups at each VA facility, and 1-2
 focus groups at each CBOC. Based on prior experience conducting focus groups with Veterans,
 the investigators believe that this number of focus groups will provide sufficient data to
 reach saturation, the point at which no new information is uncovered during group discussion.
 Two members of the research team will manage each focus group.

 Patient Focus Group Questions. A discussion guide that includes open-ended items with probes
 and follow-up questions will be used to conduct focus groups with patients. The guide
 consists of questions designed to generate discussion among participants concerning
 contextual factors, patient-centered care, and technology use for health care delivery. The
 first set of questions will assist in identifying contextual factors that affect patients'
 abilities to manage their care. The second set of questions will explore patients'
 understanding of and preferences for patient-centered care. The final set of questions will
 describe patients' awareness of, available resources, and willingness to use health
 technology.

 Data will be analyzed using constant comparative techniques consistent with a grounded-theory
 approach

 Provider Interviews. Semi-structured interviews will be conducted with healthcare providers
 at each of the sites. Providers will consist of PACT and/or primary care team members
 including nurse care managers and physicians. The investigators will use semi-structured
 interviews for providers because of the added flexibility afforded by this method with
 respect to time and scheduling. The investigators developed a semi-structured interview guide
 to address the research objectives. The first set of questions is designed to identify
 contextual factors and understand how providers attempt to address them. Data will be
 analyzed using the same process detailed for analysis of focus group data (i.e., constant
 comparative techniques consistent with grounded theory).

 Question Repository. In parallel with focus groups and interviews, the investigators'
 research assistant will review the available literature through PubMed, psycINFO and other
 reference search engines for surveys/questionnaires that include items related to areas of
 patient context. Initial search terms include: assessment tool, assessment scale, risk
 assessment, contextual factors, patient questionnaires and context specific terms such as
 technology resources, social support and patient-centered care. The investigators will
 assemble a repository of questions that could be used for the investigators' inventory. If
 there are contextual areas in which the investigators are unable to find adequate questions,
 the investigators will generate items for consideration by the Delphi panel.

 Phase II: Creating the Patient Inventory. Using findings from focus groups, information from
 the literature, and input from an expert panel the investigators will draft a patient
 inventory that can serve as a collaborative decision tool for patients and providers. The
 investigators will work with the expert panel to identify and refine the content areas for
 the inventory using a modified Delphi panel approach. The goal of the project is to develop
 an instrument that would take no more than 10-15 minutes for a patient to complete.

 Participants/procedures. A heterogeneous panel will be chosen based on participants'
 willingness to participate and knowledge of the relevant topic. Because patients are the key
 stakeholder for patient-centered care, the investigators will assemble a panel that includes
 Veteran representatives, VA providers, researchers and representatives from the
 investigators' operations partners. To maintain at least 14 respondents (70%), the
 investigators will initially recruit 20 panelists (5 in each stakeholder group).

 The investigators will conduct the Delphi process through a series of email exchanges. In the
 first email round, a list of possible items for each of the context areas will be
 distributed. Panelists will be asked to rank the importance of the areas of context
 identified, comment on whether they feel that there is redundancy in categories, and provide
 input on the relevance of items within each content area to patient context, patient-centered
 care and/or collaborative decision-making. The investigators will also ask an open-ended
 question allowing panel members to identify areas that they feel should be included.
 Responses will be entered without identification of the panelists. Each participant will be
 assigned an ID code. Categories and items for which the panelists agree do not fit or are
 redundant with other items that are better worded, and those items that are ranked very low
 will be dropped.

 A revised set of categories and items will be sent to the panelists for a second round of
 review. At that time, the panelists will repeat the process used for the first round review.
 A final draft will be sent to the panel for one more review. The investigators will also
 include feedback about qualitative comments made by panelists in each round and data about
 specific item ratings (e.g., median, lowest and highest ratings per item, etc.) The responses
 to this last review will be used to finalize the patient inventory. The investigators
 anticipate that this process will take approximately 4-5 months to complete the Inventory
 Template. Once the patient inventory is finalized, the investigators will integrate them into
 an iPad application for patient use. The iPad provides multiple advantages for collecting
 patient information, providing a portable, touch-driven multimedia experience popular across
 different demographic strata. The iPad inventory will include skip patterns for respondents
 to jump over non-relevant items, out-of-range checking and validation so that respondents do
 not enter erroneous information, drop-down boxes, and utilize examples and explanations for
 clarity. Patients will have the opportunity to "not answer" any items, based on personal
 comfort of what information should be shared.

 The investigators will perform iterative testing of the iPad version of the inventory to
 ensure acceptability by patients. All information entered in the iPad will be kept private
 and secure, such that other patients cannot access any stored data. As an additional
 safeguard, the iPad will "time out" if not used for some duration of time to prevent
 extraneous viewing by others. The iPad will be used in waiting areas by patients prior to
 encounters with health care providers. Research staff will maintain the iPad, including
 charging, storing securely when not in use to prevent theft, applying anti-bacterial cleaner,
 and monitoring device use.

 When patients use the iPad inventory, the application will create a brief report summarizing
 patient preferences and contextual factors. This report will be available to the PACT at the
 point of care to facilitate patient/provider communication and collaborative decision-making.
 For the initial study, research staff will facilitate communication of the report to health
 care providers by generating a paper summary that patients will hand to providers. However,
 design and testing will consider future implementation strategies, including incorporation
 into clinical workflow patterns and adoption by clinical staff.

 Phase III: Testing the Patient Inventory. The investigators plan to pilot the patient
 inventory in a sample of Veterans in two sets of PACT clinics; one at Hines and the other at
 JBVA. The study design is a randomized controlled trial. The investigators will randomize
 half the patients to complete the patient inventory and the other half to a control condition
 (i.e., health video). The investigators will stratify by Veterans Affairs Medical Center
 (VAMC) to ensure that there are equal samples. The randomization scheme will be developed
 using computer generated random assignment.

 Eligible patients will be identified and recruited from the PACT clinics at Hines and Jesse
 Brown VAMCs. No subjects will be excluded based on gender, race, or ethnicity. Eligibility
 criteria include: (1) adult, age 18 or over; (2) assigned primary care provider in PACT
 clinic; (3) no history of dementia; (4) no blindness (unable to view iPad app). Only patients
 of participating providers will be eligible for the study, to ensure both patient and
 provider consent to audio-recordings and study procedures.

 It is possible that providers will discern that their visits with patients that involve the
 use of 'summary' forms are the same visits that will be audio-recorded. To address the
 likelihood of a Hawthorne effect the following strategies will been undertaken. First,
 providers will be informed that some of the visits that are recorded will include patients
 providing additional written information for providers while other visits will not include
 this information. Second, the investigators will undertake sensitivity analyses comparing
 data from the first 10% of audio-recorded encounters to the 2nd and 5th 10% of encounters.
 The investigators will assess whether provider behavior is significantly different at these
 points in time. If the first several visits result in different behavior then later visits,
 the investigators can eliminate the first recordings from their analyses. Thus, the
 investigators will over-recruit patients by 10%, with patients evenly distributed between
 intervention and control arms.

 Intervention: The patient inventory developed through focus groups and Delphi panel will
 serve as the intervention. The inventory will be deployed using an iPad. Patients will
 provide a copy of the summary to their provider at the beginning of their visit.

 Control Condition. To address concerns about a Hawthorne effect, the investigators will
 implement an attention control. The control group will use the iPad to will view a brief
 health video (e.g., 8-10 minutes) containing general health information. The VA National
 Center for Health Promotion and Disease Prevention (NCP) is currently developing a set of
 video-based health living messages. The investigators will utilize one of these videos in for
 their control group. Alternatively, Agency for Healthcare Research and Quality (AHRQ) has
 developed several videos that are available at no cost and are 508 compliant. The 'Be
 involved in your health care - Questions are the answer' is a 7 minute video that is focused
 on talking to your provider and asking questions
 (http://www.ahr.gov/questions/video/waitroom/). Control patients will also be asked to
 audio-record their encounter with their provider, but not to reveal that they are doing so.

 Patients will complete the informed consent process, agreeing to use of the iPad to either
 complete an inventory or view a video about their health, willingness to have their encounter
 with the provider audio recorded, and completion of a set of questionnaires following the
 clinic visit. Consenting patients will complete the patient inventory or view the video on an
 iPad prior to their clinic visit. A research assistant will instruct the patient on how to
 use the iPad and what the patient needs to do to complete the questionnaire (in the
 intervention condition). The RA will be available to answer questions or provide additional
 instruction, as needed. After intervention patients complete the questionnaire, the RA will
 hook the iPad up to a portable printer so that a hard copy of the inventory can be generated
 for patients to immediately give their provider. The patient will proceed to his/her visit
 with the provider. To ensure adequate use of the iPad and the patient inventory, the RA will
 be available to assist subjects in use as necessary. The research team will collect
 information on how frequently assistance is needed, and form of support provided. The
 investigators estimate the inventory will take approximately 10-15 minutes to complete.
 Patients will have the opportunity to complete the inventory in a designated, private area to
 reduce interruptions and distractions.

 In both the intervention and control arms, patients will be asked to conceal a small
 recording device in their pocket and/or bag in order to record their conversation with the
 provider. The patient will be told that the provider has agreed to be recorded during some of
 their patient visits but that the provider will not know which visits will be recorded. The
 RA will turn the device on before handing it to the patient and the patient will return the
 recorder after the visit. Weiner has successfully utilized this strategy in two HSR&D funded
 studies.

 Following the clinic visit, the patient will be asked to complete a set of questionnaires.
 These items will be completed using paper and pencil. The investigators will also ask
 patients to indicate whether they have used any technology for their health care using a
 checklist (use of home telehealth, CVT, secure messaging, prescription refills through
 HealtheVet [MHV], use of mobile apps like PTSD coach, accessing VA Facebook or twitter sites)
 and whether any future care plans include use of technology.

 Providers. PACT providers will also serve as research subjects for the study. The
 investigators will ask providers to consent to having some of their encounters recorded over
 a one year period. The investigators will explain to providers that they are interested in
 examining the effects of providing or not providing additional patient-generated information
 to providers at the time of their visit on patient/provider interactions. Providers will be
 assured that no identifiable information will be recorded on the transcriptions (e.g.,
 providers will be referred to by a unique study ID number). The investigators will also ask
 providers to participate in a debriefing interview at the end of the study to ask them about
 the value and use of the pre-visit patient inventory in their encounters with patients. Only
 patients of providers who consent to participate will be approached about study
 participation.

 Study Measures: To determine patient-centeredness the investigators will ask patients to tell
 them about their experiences with care and the extent to which care they received met their
 preferences and addressed their contextual factors. The investigators will utilize measures
 of patient-centeredness including the Consultation and Relational Empathy (CARE) measure and
 the Consultation Care Measure (CCM).

 To objectively evaluate the extent to which care being provided is patient-centered, the
 investigators will obtain audiotapes of patient/provider encounters and code them using
 Weiner's 4C analysis measure and the Informed Decision Making (IDM) tool to evaluate
 collaborative decision making during patient/provider encounters. These measures are
 described below:

 CARE. The Consultation and Relational Empathy (CARE) Measure is a process measure of empathy
 and holistic care in the context of a therapeutic relationship. Mercer defines empathy in the
 medical encounter as the ability of the provider to understand the patient's situation,
 perspective and feelings; to communicate to the patient what their understanding is and check
 whether s/he is correct in this interpretation, and then to act in a way that is helpful and
 therapeutic .This description fits into many definitions of patient-centered care. The CARE
 measure has 10 items and it specifically asks about today's consultation. To better fit the
 definition of care in the US, the investigators will change the word consultation to 'visit.'
 For each item, the respondent rates their response as poor, fair, good, very good, excellent,
 or does not apply. Questions include: How was the provider at 'making you feel at ease',
 'letting you tell your "story"', 'being positive.' The score for each item is added for a
 maximum score of 50 and minimum of 10; a higher score reflects greater
 'patient-centeredness'.

 CCM. The Consultation Care Measure (CCM) measures a patient's perceptions of patient-centered
 care during their last visit with their provider. There are 5 subscales in this 21-item
 scale. CCM assesses communication and partnership (11 items), personal relationship (3
 items), health promotion (2 items), positive and clear approach to the problem (3 items),
 interest in effect on life (2 items). The items use a 4-point Likert scale for scoring from
 1= very strongly agree to 2= strongly agree to 3=agree to 4=neutral/disagree. Cronbach's
 reliabilities range from 0.84 to 0.96 for the subscales. A higher level of
 patient-centeredness based on the CCM (lower score) was associated with short-term better
 health outcomes.

 Informed Decision Making (IDM) measures the extent to which decision making involving the
 patient and provider includes 7 elements of a complete decision. The 7 elements include:
 discussion of patient's role in decision making, clinic issue or nature of the decision,
 alternatives, pro and cons (benefits and risks), uncertainties, patient understanding, and
 patient preference. For each decision, a score between 0-7 is assigned based on review of the
 audio-recorded encounter. A higher score is expected if the decision is more complex
 (decisions can be categorized as basic, intermediate or complex). For basic decisions (e.g.,
 refilling a medication), a score of 2-3 would indicate a good IDM event, while a more
 intermediate decision (e.g., prescribing use of a new piece of equipment - such as CPAP)
 should result in a score of 5-6 reflecting an informed decision; and a complex decision
 (e.g., lifestyle counseling) would receive a score of 7 if all the elements of the IDM were
 noted during the decision.

 Content Coding for Contextualizing Care (4C). The 4C analysis is methodology for assessing
 patient centered clinical decision making. Specifically, 4C rates encounters based on whether
 the provider (a) probes for clinically relevant context and (b) plans the care accordingly.
 The analysis is generated from both the patient's medical record and from an audio recording
 of the provider-patient visit. 4C may be conducted by as few as two individuals or as many as
 five, with the additional personnel required to verify inter-rater reliability and other
 sources of evidence for validity. Coding will be done by an experienced coder who has worked
 with Dr. Weiner on two prior studies utilizing the 4C analysis. Using this coding we will
 determine how often providers probe for contextual factors during patient encounters, and how
 often they incorporate this information into their care planning for that encounter.

 Sample size/power: The primary measure of patient-centered care is the CARE measure.
 Normative data on the CARE indicates a mean score of 40.8 (range 10-50) with a
 between-physician variance of patients receiving care from the same physician, = 9.0247, and
 within-patient variance = 69.2149, for a total variance = 78.2396 (SD=8.85) (Mercer 2005).
 Without taking into account related patient CARE scores of patients being treated by the same
 physician, 64 patients in both control and intervention groups (total n=128) will be adequate
 to detect a moderate effect size (Cohen's d=0.5) at the 0.05 level with 0.8 power. Of course,
 patients receiving care from the same physician might respond similarly to questions
 regarding empathy and holistic care pertaining to their physician, as recorded by the CARE
 measure. The multiplicative effect on the standard error due to clustering is 1 + (m-1)*ICC,
 where m represents the size of each cluster (patients per physician) and ICC the intraclass
 correlation of same-physician patient CARE outcomes. 25 doctors with 11 patients each, or 24
 doctors with 12 patients each will be sufficient in detecting a moderate effect size (Cohen's
 d=0.5) at the 0.05 level with 0.8 power. Accounting for the possibility that patients may
 change their mind, be too fatigued, and/or have not enough time to complete the post-visit
 questions, or deficiencies in physician attrition, the investigators have added an additional
 10% (28 more patients/25-26 physicians) to the total.

 The total study sample size is 25-26 providers and 300-308; 150-154 patients per group.

 Patients enrolled in the PACT clinics at Hines and Jesse Brown will serve as the patient
 subject pool and the providers in these PACT teams will serve as the provider subjects. Only
 patients who are in the panels of providers who consent to participate will be recruited for
 the study.

 Analysis: Descriptive statistics including frequencies and means will be calculated to
 characterize the investigators' patient sample, including demographics (e.g., mean age,
 gender, ethnicity/race). The investigators will utilize t-tests to make comparisons of
 intervention and comparison groups on the patient measures. The overall scores and the
 subscale scores for the CARE and the CCM will be compared using t-tests. They will then
 examine the extent to which other characteristics including study site (Hines, JBVA) and
 patient characteristics (age, race) account for differences in ratings of patient-centered
 care using linear regression models. The investigators will use the standard formula Y = a +
 b1X + b2X +. biX, with no more than 15 covariates (using 1 covariate for every 10
 observations) in addition to the intervention effect (b1). As many patients may have the same
 provider, there could be an effect for provider. They will explore use of multi-level
 modeling to account for provider effects.

 4C Coding and Analysis. 4C analysis rates encounters based on whether the provider probes for
 clinically relevant context and plans care accordingly. The analysis uses both the patient's
 medical record and an audio- recording of the provider-patient visit. 4C coding includes the
 following:

 1. Contextual red flag identification: Following an encounter, the first step for coders is
 to determine if there were any contextual red flags that the provider would need to have
 explored to provide appropriate care. Red flags include things like missed appointments,
 non-adherence of medications or receipt of laboratory tests or deterioration of chronic
 illness (e.g., uncontrolled blood pressure). A contextual red flag is defined as
 anything a patient says or that was observed about his situation or behavior that
 suggests that contextual factors were not addressed and may be contributing to problems
 with their care. The search for contextual red flags begins with a structured medical
 record review by a contextual red flag "screener". If no flags are found in the medical
 record the coder listens to the audio-recording to determine if the patient made
 statements suggesting underlying contextual issues essential to their care. For example:
 a. Contextual red flag identified from chart review: Rising systolic blood pressure in
 patient with hypertension who has been previously well controlled. b. Contextual red
 flag identified from audio-recording: Visually impaired Veteran with hypertension
 mentions that his daughter, who sets up his medications in a daily pill box, has
 relocated to another city for her job.

 2. Coder(s) formulate an unambiguous direct probe of red flag: The coder(s) compose an
 unambiguous provider probe to the identified contextual red flag, e.g. "I notice that
 your hypertension used to be well controlled but your blood pressure has been very high
 over the last couple of months. What do you think is going on in your life that might be
 a factor in this problem?" The probe is always in the form of a question by the provider
 in response to a red flag. The purpose of this exercise is to help the coder identify
 what s/he should be listening for to indicate that the provider has noticed and is
 pursuing the contextual red flag.

 3. Coder listens for clinician probe: The coder then listens for whether the provider
 pursued the contextual red flag in a manner that substantively approximates their direct
 probe.

 4. Coder listens for a 'patient reveal' in response to a probe: If the provider probed, the
 coder determines whether the patient revealed contextual information that is relevant to
 care, such as "It's a lot more difficult for me to remember to take my medication when
 I'm supposed to since my daughter left."

 5. Coder formulates an unambiguous direct response to the patient reveal: If the patient
 reveals contextual issues in response to the probe, the coder formulates an unambiguous
 response to the reveal that indicates the provider recognized the need to contextualize
 the care plan, e.g. "Let's talk about how you could change your medication schedule to
 help you remember."

 6. Coder listens for contextualization of care plan: The coder then listens for whether the
 provider recommends a plan of care that substantively approximates their direct probe.
 (e.g., switches all medications to morning)

 Because coding can be quite nuanced, Weiner et al. has developed a comprehensive training
 manual, similar to those developed for other coding systems, such as Debra Roter's "Roter
 Interaction Analysis System" (RIAS), utilized for coding physician patient communication.
 RIAS codes interactional process behaviors (e.g. when clinician or patient asks open vs
 closed ended questions, gives instructions, asks for understanding, paraphrases, etc.) but
 not content. The 4C coding manual is available from Dr. Weiner, co-inv on the study.
 (http://dvn.iq.harvard.edu/dvn/dv/4C)

 IDM Analysis. Reliability of coding between three coders will be established with at least
 85% concurrence before the coders will individually code encounters. The investigators will
 recheck reliability after every 25 encounters by having all coders code the same encounter to
 ensure that they are all coding in a similar manner. If concurrence is below 75%, the
 investigators will review coding criteria and re-establish concurrence using the next 2-3
 audiotaped encounters. Coders will listen to the audiotapes and identify the number and types
 of decisions that occurred during each encounter. Then they will select the decision of more
 interest/concern of the patient and code that decision using the IDM criteria. The
 investigators will compare the mean IDM scores by decision type by intervention vs. control
 groups to determine whether use of the inventory facilitates more informed decision making

 Cost impact: In this study, the investigators will conduct a cost-identification analysis to
 assess the cost of providing the intervention in this study. Additionally, they will conduct
 a budget impact analysis to assess the impact on costs to a VA medical center of implementing
 the patient inventory. The cost of the intervention includes the cost of the equipment needed
 for the intervention (i.e., the iPad and printer) and the cost of any change in clinic
 personnel time that results from the intervention. The patient inventories may impact clinic
 personnel's time due to the need to train and assist the patient in entering the inventory as
 well as potentially changing the duration of the clinic visit due to discussions facilitated
 by the patient inventory. The RA will record 1) the time it takes to train each patient to
 use the iPad, 2) the time it takes for each patient to complete the patient inventory and the
 proportion of this time the RA spent assisting the patient, and 3) the time it takes to print
 the inventory for the patient to give to the provider. Additionally, the RA will record
 whether it interferes with being on time for the clinic visit. The RA will also record the
 length of the provider/patient encounter by recording the time the provider entered the
 clinic room to see the patient and then when he leaves the room/completes the visit. In order
 to make comparisons to usual care, the RA also will record the length of time of usual
 encounters by timing the encounters of the control patients in the randomized.

 The investigators will also conduct a budget impact analysis to evaluate the cost of
 implementing the intervention at a VA medical center. The estimated budget impact on the
 medical center will be sum of the purchase price of the equipment, the cost of the clerical
 personnel's time, and the cost of physicians' time (which will be estimated as an average
 physician's wage multiplied by the difference in the average time of clinic visits between
 intervention and control patients). The investigators will estimate the total cost of
 providing the intervention to patients under the alternative scenarios regarding the number
 of patients who would complete the inventory and the amount of equipment that would need to
 be purchased.
Inclusion Criteria:

 Phase I:

 -  VA patients who have had some experience with care receipt through technology (e.g.,
 home telehealth, CVT, secure messaging with providers).

 -  A second group will be conducted with patients who have not had experience receiving
 care through technology.

 -  There are no other specific inclusion criteria and the investigators plan to recruit
 both male and female Veterans, as well as minorities.

 Phase II:

 -  Veterans who receive care from VA and are comfortable using the Internet.

 -  There are no other specific inclusion criteria and the investigators plan to recruit
 both male and female Veterans, as well as minorities.

 Phase III:

 -  Veterans who receive care from Hines VA or Jesse Brown VA in a primary care/PACT
 clinic.

 -  No subjects will be excluded based on gender, race, or ethnicity. Eligibility criteria
 include:

 -  (1) adult, age 18 or over

 -  (2) assigned primary care provider in PACT clinic

 -  (3) no history of dementia

 -  (4) no blindness (unable to view iPad app).

 -  Only patients of participating providers will be eligible for the study, to ensure
 both patient and provider consent to audio-recordings and study procedures.

 -  There are no other specific inclusion criteria and the investigators plan to recruit
 both male and female Veterans, as well as minorities.

 Exclusion Criteria:

 -  A history of dementia

 -  Blindness