The Veterans Health Administration (VHA), a part of the US Department of Veterans Affairs (VA), is the largest healthcare system in the United States. As a system that serves more than 9 million patients, the VHA generates massive volumes of data – data that can be used to improve our understanding of various conditions and patient care practices. Dr. Shimrit Keddem is an Assistant Professor of Family Medicine and Community Health at the University of Pennsylvania’s Perelman School of Medicine and a Core Investigator for the Center for Health Equity Research and Promotion (CHERP) at the VHA.* Her work for the VA is based at the Corporal Michael J. Crescenz Medical Center in Philadelphia.
In episode 38 of NVivo’s Between the Data podcast, Dr. Keddem spoke to Dr. Stacy Penna about how qualitative and mixed methods research have contributed to patient-centered care at the VA. This article unpacks Dr. Keddem’s key insights about driving evidence-based healthcare practices through implementation science based on research data – and how to manage large, qualitative datasets using software for qualitative data analysis.
Patient-Centered Care: A Cultural Shift in Healthcare
Patient-centered care is a philosophy of healthcare practice where the individual patient’s needs and desired health outcomes are at the center of every decision by practitioners. According to a 2017 New England Journal of Medicine Catalyst article, patient-centered care includes the following characteristics:
- Practitioners collaborate to coordinate care and ensure it is accessible.
- Decision making includes patients and their families, both for individual situations and across the system.
- Patients and their families benefit from timely and transparent sharing of information to help them make informed decisions.
- Practitioners respect the values, cultural traditions, life circumstances, and preferences of patients and their families.
- Care focuses on the patient's emotional well-being as well as physical comfort.
Dr. Keddem noted that patient-centered care is about 20 years old, and that adopting patient-centered care principles requires cultural shifts within healthcare systems. At the VHA, her research helps inform and improve this cultural shift.
“Patient-centered care is really important everywhere, not just at the VA,” she explained. “I think of it as sort of like meeting the patients where they are, and there are many different ways to do that.”
Implementation Science: Putting Evidence-Based Practices to Work
Much of Dr. Keddem’s research uses implementation science to translate research into practice. The National Cancer Institute at the National Institutes of Health (NIH) defines implementation science as “the study of methods to promote the adoption and integration of evidence-based practices, interventions, and policies into routine health care and public health settings.” In other words, when research indicates that a certain type of practice helps improve care, implementation science helps researchers and practitioners understand how best to put that practice to work in the real world.
“The VA is really one of the leaders in implementation science,” said Dr. Keddem. Implementation science is grounded in qualitative research which helps clinical directors and policymakers understand what the conditions are like for practitioners, and what barriers exist on the ground that might prevent successful implementation of a new practice.
Dr. Keddem gave the example of a randomized controlled trial that shows a specific type of interviewing technique in therapy which supports reduced addiction. Implementation science would look at what steps would need to be taken to incorporate that technique into existing practices. Dr. Keddem’s team would then help train practitioners who plan to implement the new technique on how to adapt their approach.
The practitioners can then provide feedback to her team on how the implementation went and what adjustments they had to make in the moment to make it work. In the case of the addiction counseling technique, this might look like having a nurse practitioner conduct the interview because a social worker or other counselor was not available.
“We'll sort of keep a back-and-forth channel of communication between us and who's implementing [the change],” Dr. Keddem explained. “The goal is to just make it as effective and…possible as it can be.”
Why the VA Is a Rich Environment for Researchers and Qualitative Analysis
At the VHA, Dr. Keddem is both an independent investigator and a qualitative methodologist. While she conducts her own research, she also collaborates with VHA staff and researchers in designing their studies, choosing their research methods, and helping them access the qualitative research software and other resources they need to do their work. She noted that while conducting research within the VHA looks similar to conducting research at Penn or another university, there is a key difference – the size of the VA network and the volume of data.
On the quantitative side, VA researchers can conduct electronic health record analyses on millions of patients. On the qualitative side, there are many surveys that collect data at the patient and facility level. One of these is the Survey of Healthcare Experiences of Patients (SHEP). The SHEP initiative is important for understanding patient-centered care. “It's about patient satisfaction and that's a big piece of patient-centered care,” explained Dr. Keddem.
VA researchers can also conduct their own qualitative research within the overall VA network which could include site visits, focus groups, and field observations. Dr. Keddem also noted how VA researchers can connect with scientists and policy researchers at facilities throughout the country to ask questions and collaborate. For her, putting a mixed methods research approach to work within this large system helps to “integrate the voices of our research participants [so] we know that our findings are sort of grounded in the experiences of our patients, our providers and our staff.”
Ultimately, said Dr. Keddem, research at the VA is rewarding and challenging because of its focus on driving better results for patients. “They really have an expectation that you have, as much as possible, an immediate impact on veterans.”
Managing Large Datasets with QDA Software and Analysis Tools
Dr. Penna called attention to two studies Dr. Keddem had published based on VA data: 2018’s “Improving Patient-Centered Care: How Clinical Staff Overcome Barriers to Patient Engagement at the VHA” and 2020’s “The Gears of Knowledge Translation: Process Evaluation of the Dissemination and Implementation of a Patient Engagement Toolkit.” Both these studies were “large and longitudinal,” in Dr. Penna’s words, and incorporated qualitative data from hundreds of interviews and site visits. Dr. Keddem explained how qualitative research software played a critical role in making these studies feasible.
First, she noted that because her research is focused on health services, there is a time limit involved – studies must be completed quickly to produce a result for patients.
“With these huge projects where we have literally hundreds of data points, I just don't think it would be possible to do what we do [without tools for qualitative data],” said Dr. Keddem. Given that her teams can vary from two to 10 people, the collaboration and sharing tools provided by qualitative data analysis software such as NVivo and NVivo Collaboration Cloud helps keep work organized and on track.
Learn how NVivo Collaboration Cloud can help improve your research team's experience by letting you securely share and analyze qualitative data in real-time across Windows and Mac operating systems.
Coding begins as soon as interviews are conducted, explained Dr. Keddem. “We don't wait until everything is transcribed, because you can imagine, with hundreds of interviews, that would be a major backlog.”
Her team will meet to collaboratively develop an initial codebook based on some sample transcripts, and then that codebook will be refined as more interviews come in. “The initial codebook is just a draft,” she added. “It's something that's going to need to be put to the test.”
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Qualitative Research Software’s Role in CHERP Success
Dr. Keddem gave an example of how qualitative research software helped her find insights within the data for her 2020 paper, “The Gears of Knowledge Translation: Process Evaluation of the Dissemination and Implementation of a Patient Engagement Toolkit.”
She and her colleagues, Dr. Judith Long and Dr. Rachel Werner, collected hundreds of interviews and field notes, “But we were interested in how people's responses on the qualitative interviews and our observations and so on differed by facility characteristics.”
Dr. Keddem and her team were able to classify each interview with a set of facility characteristics, such as whether the facility scored higher or lower on patient satisfaction rates based on SHEP data.
“Then we can miraculously let the software give us these matrices where we can see exactly the differences [among facilities] and how people responded to questions based on those characteristics,” said Dr. Keddem.
She also notes that performing qualitative data analysis with software helps strip out any biases researchers may have about what they expect to find going into their work. “I do think the software also helps us be less biased and less going with our gut feelings and more going by what's [in the data],” said Dr. Keddem.
What’s Next for Dr. Keddem
Dr. Keddem continues to work on improving patient-centered care for veterans through implementation science. With support from a VA Health Services Career Development grant, she is currently carrying out a large multi-year research project looking at screening for sexually transmitted infections (STIs) among women veterans.
While the project has multiple aims and is ongoing, one outcome so far has the potential to improve care. “Only about 22% of women under age 25 received the recommended testing for sexually transmitted infection,” Dr. Keddem explained.
Her team was able to recommend an implementation that could improve STI screening rates: a pop-up reminder box that appears in the patient health record when they are being seen by a practitioner. The VA Office of Women’s Health has begun to roll out the clinical reminder within its healthcare records.
“We have a long way to go, but it's an excellent outcome,” Dr. Keddem said. “It's very exciting to be part of work that directly interfaces with the clinical operations and outcomes in this way.”
Learn More About This Research and NVivo Qualitative Data Analysis Software (QDAs)
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*The views expressed by Dr. Keddem in the podcast and in this article are her own, and do not necessarily reflect the position or policy of the Department of Veteran Affairs or the United States government.
**Source: Scopus Data Analysis 2024