case study of psychiatric patient

Case Study 1: Psych Patient in ED

Aaron Smith, age 20, is a psychiatric patient with bipolar disorder. At the request of his father, he is brought by police to the Emergency Department. This is his third visit to the ED for psychiatric treatment this year.

Personal History and Recent Events

Last month, Aaron was expelled from his college dorm due to aggressive behavior and substance abuse. He has moved back into his parents' home. Today, in an outburst, he put his fist through a wall and then turned his rage toward his father. His parents suspect he has stopped taking his medication for bipolar disorder.

Aaron's Demeanor upon Arrival

Aaron displays classic signs of potential to become violent. These include:

• disheveled appearance
• clenched fists

Cues from Hospital Records

A quick look at Aaron's hospital records reveals a history of violent behavior:

• Aaron is being treated for bipolar disorder with prescribed medications.
• He has had two other recent ED visits before this one: once for disruptive, violent behavior, and once for a drug overdose.
• He rated "high" for dangerousness on assessment from a previous visit.

Triage Reveals Suicidal Thoughts

The triage nurse questions Aaron to help determine the extent of present danger. After several prompts to get beyond surface answers, the nurse learns that besides his violent outburst at home, Aaron had planned to kill himself by crashing his car, which increases his risk of danger to others.

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Patient Case Presentation

Figure 1.  Blue and silver stethoscope (Pixabay, N.D.)

Ms. S.W. is a 48-year-old white female who presented to an outpatient community mental health agency for evaluation of depressive symptoms. Over the past eight weeks she has experienced sad mood every day, which she describes as a feeling of hopelessness and emptiness. She also noticed other changes about herself, including decreased appetite, insomnia, fatigue, and poor ability to concentrate. The things that used to bring Ms. S.W. joy, such as gardening and listening to podcasts, are no longer bringing her the same happiness they used to. She became especially concerned as within the past two weeks she also started experiencing feelings of worthlessness, the perception that she is a burden to others, and fleeting thoughts of death/suicide.

Ms. S.W. acknowledges that she has numerous stressors in her life. She reports that her daughter’s grades have been steadily declining over the past two semesters and she is unsure if her daughter will be attending college anymore. Her relationship with her son is somewhat strained as she and his father are not on good terms and her son feels Ms. S.W. is at fault for this. She feels her career has been unfulfilling and though she’d like to go back to school, this isn’t possible given the family’s tight finances/the patient raising a family on a single income.

Ms. S.W. has experienced symptoms of depression previously, but she does not think the symptoms have ever been as severe as they are currently. She has taken antidepressants in the past and was generally adherent to them, but she believes that therapy was more helpful than the medications. She denies ever having history of manic or hypomanic episodes. She has been unable to connect to a mental health agency in several years due to lack of time and feeling that she could manage the symptoms on her own. She now feels that this is her last option and is looking for ongoing outpatient mental health treatment.

Past Medical History

• Hypertension, diagnosed at age 41

Past Surgical History

• Wisdom teeth extraction, age 22

Pertinent Family History

• Mother with history of Major Depressive Disorder, treated with antidepressants
• Maternal grandmother with history of Major Depressive Disorder, Generalized Anxiety Disorder
• Brother with history of suicide attempt and subsequent inpatient psychiatric hospitalization,
• Brother with history of Alcohol Use Disorder
• Father died from lung cancer (2012)

Pertinent Social History

• Works full-time as an enrollment specialist for Columbus City Schools since 2006
• Has two children, a daughter age 17 and a son age 14
• Divorced in 2015, currently single
• History of some emotional abuse and neglect from mother during childhood, otherwise denies history of trauma, including physical and sexual abuse
• Smoking 1/2 PPD of cigarettes
• Occasional alcohol use (approximately 1-2 glasses of wine 1-2 times weekly; patient had not had any alcohol consumption for the past year until two weeks ago)

Module 11: Schizophrenia Spectrum and Other Psychotic Disorders

Case studies: schizophrenia spectrum disorders, learning objectives.

• Identify schizophrenia and psychotic disorders in case studies

Case Study: Bryant

Thirty-five-year-old Bryant was admitted to the hospital because of ritualistic behaviors, depression, and distrust. At the time of admission, prominent ritualistic behaviors and depression misled clinicians to diagnose Bryant with obsessive-compulsive disorder (OCD). Shortly after, psychotic symptoms such as disorganized thoughts and delusion of control were noticeable. He told the doctors he has not been receiving any treatment, was not on any substance or medication, and has been experiencing these symptoms for about two weeks. Throughout the course of his treatment, the doctors noticed that he developed a catatonic stupor and a respiratory infection, which was identified by respiratory symptoms, blood tests, and a chest X-ray. To treat the psychotic symptoms, catatonic stupor, and respiratory infection, risperidone, MECT, and ceftriaxone (antibiotic) were administered, and these therapies proved to be dramatically effective. [1]

Case report

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Case Scenario 1: Patient With Bipolar 1 Disorder Reports New Onset Movements

In this custom video series, experts share overall impressions of a female patient with bipolar 1 disorder who develops new onset movements suggesting tardive dyskinesia and the rationale for intervening with VMAT2 therapy.

EP: 1 . Case Scenario 1: Patient With Bipolar 1 Disorder Reports New Onset Movements

EP: 2 . Case Scenario 2: Patient With Tardive Dyskinesia Prescribed a VMAT2 Inhibitor

EP: 3 . Screening for Tardive Dyskinesia and Intervening With VMAT2 Inhibitors

Ep: 4 . assessing severity of tardive dyskinesia, ep: 5 . managing patients on antipsychotic therapy, ep: 6 . anticholinergic medications and impaired cognition, ep: 7 . vmat2 inhibitors for tardive dyskinesia, ep: 8 . treating tardive dyskinesia with a vmat2 inhibitor, ep: 9 . prevention and early detection of tardive dyskinesia.

EP: 10 . Expert Perspectives on Recognition and Management of Tardive Dyskinesia

Leslie L. Citrome, MD, MPH: Welcome to this Psychiatric Times Case-Based Psych Perspectives, expert perspectives on recognition and management of tardive dyskinesia. I am Dr. Leslie Citrome, clinical professor of Psychiatry and Behavioral Sciences at New York Medical College in Valhalla, New York. And joining me is Dr. Rose Mary Xavier, research scientist and psychiatric nurse practitioner with the University of North Carolina at Chapel Hill. Welcome.

Rose Mary Xavier, PhD, MS, RN, PMHNP-BC: Thank you. I am happy to be here.

Leslie L. Citrome, MD, MPH: I am happy to have this conversation here. It is very clinically relevant to our audience. The goal of our discussion today is to provide an overview of tardive dyskinesia, as well as offer insights into the management of this detrimental disease. Let’s start by reviewing a couple of case scenarios and try to figure this out. The first one is a patient with bipolar 1 disorder who reports new onset of movements. This is a 54-year-old woman who received a diagnosis of bipolar 1 disorder at the age of 32, after requiring hospitalization for an acute manic episode. She was started on lithium at that time. She relapsed at age 41 with a florid manic episode requiring psychiatric hospitalization, resulting in an atypical antipsychotic being added to her regimen. She presents for routine follow-up. Her only concern relates to feedback received from her husband. About 6 months ago, her husband began observing constant movement of both her hands while watching television in the living room. He had not seen these types of movements by her before, and they seemed to be increasing in degree. He also frequently asked her if she was chewing gum or if she had something in her eye. This case tells us something about a woman exposed to a dopamine receptor blocking agent, that is an antipsychotic, who develops abnormal movements after some delay. It did not happen right away, but over time they became noticeable. Dr. Xavier, what is your overall impression?

Rose Mary Xavier, PhD, MS, RN, PMHNP-BC: My impression of this case is focusing on the use of antipsychotic medications for treatment of mood disorders, or disorders other than a primary psychotic disorder. When, just reading through this case, there are several things that stand out. Now she is a 54-year-old female. When we look at the risk factors for development of tardive dyskinesia, there are several things that stand out from the studies that have been published. We know that female sex and that the duration of treatment with antipsychotic medications increase the risk for developing tardive dyskinesia. So here we have a 54-year-old female. She has been diagnosed with bipolar disorder. Even though she was started on treatment with lithium, she relapsed at the age of 41 when an atypical antipsychotic medication was added. That is a 13-year history of treatment with antipsychotic medications. And just thinking about, going back to the training period in recent times, we also think about old generation medications, so the first-generation medications would cause tardive dyskinesia. We do not often hear about atypical antipsychotics, but we have data coming in that show that just because a patient is on an atypical medication, it does not diminish the risk for TD [tardive dyskinesia]. The next thing that comes to us is the type of movements that this patient has had. When you look at the case history, we know it has been about 6 months. She has constant movement of both the hands which is increasing in degree progressively, and she has chewing gum type of moments, as well as there is something in her eyes. So talk about the blepharospasm that could occur with TD. She has 4 different types of moments that have been progressively increasing. So it’s a very interesting case, and I look forward to hearing what your thoughts are.

Leslie L. Citrome, MD, MPH: Well, you have highlighted the important points here. She has had a multi-year exposure to an atypical antipsychotic. Atypical antipsychotics today still block postsynaptic dopamine receptors, and we know that is a key ingredient in perhaps the causation of tardive dyskinesia. And her movements, which appeared over time, are delayed. So tardive dyskinesia, tardive delayed dyskinesia, abnormal movement. It all makes sense that that is what we are going to be thinking about in terms of a drug induced movement disorder with her. And I think you pointed out a very important aspect about our treatments today. Although we use atypical antipsychotics, most of the time, they still incur a risk for tardive dyskinesia. They are better in terms of other drug induced movement disorders dramatically, and we do not see as much drug induced Parkinsonism. For example, that rhythmic tremor that appears right after you start an antipsychotic with the shuffling gait or the rigidity, we see a lot less of that. But there is still this liability for tardive dyskinesia. Epidemiological studies tell us that perhaps the prevalence is a little lower with atypical antipsychotics, but it is certainly not zero. My concern with her though is that she is deriving significant benefit from her regimen currently. It is keeping her stable, euthymic. It is preventing the recurrence of mania, which is really devastating for her. It required hospitalization for example. And we know it is very disruptive to functioning. She needs her medicine. And one of the things we cannot really do is stop the antipsychotic. This is what has kept her stable. We need to look at interventions that will allow us to continue her ongoing treatment for her underlying psychiatric disorder. The option in my mind would be something like a VMAT2 [vesicular monoamine transporter type 2] inhibitor, of which two are approved by the FDA [Food and Drug Administration] for the treatment of tardive dyskinesia, which are added to a person's ongoing regimen. If the patient feels secure with their current long-standing regimen, and I'm comfortable with continuing it, and there is a real concern about relapse, that would be my option. And this ties in with our next case where we are going to talk about a patient with tardive dyskinesia who is prescribed a VMAT2 inhibitor.

Transcript edited for clarity.

Not All That Writhes Is Tardive Dyskinesia

Expert Perspectives on Recognition and Management of Tardive Dyskinesia

Varenicline and Tardive Dyskinesia in Schizophrenia

Patients With Tardive Dyskinesia Feel Unheard, Social Media Listens

Tardive Dyskinesia Facts and Figures

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• Open access
• Published: 17 April 2024

Four-year follow-up of psychiatric and psychosomatic profile in patients with Inflammatory Bowel Disease (IBD)

• Sara Gostoli   ORCID: orcid.org/0000-0002-5828-4654 1 ,
• Francesco Ferrara 2 ,
• Ludovica Quintavalle 1 ,
• Sara Tommasino 1 ,
• Graziano Gigante 1 ,
• Maria Montecchiarini 1 ,
• Alessia Urgese 1 ,
• Francesco Guolo 3 ,
• Regina Subach 1 ,
• Angelica D’Oronzo 1 ,
• Annamaria Polifemo 2 ,
• Federica Buonfiglioli 2 ,
• Vincenzo Cennamo 2 &
• Chiara Rafanelli   ORCID: orcid.org/0000-0003-3025-7918 1  

BMC Psychology volume  12 , Article number:  211 ( 2024 ) Cite this article

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Metrics details

Psychological characterization of patients affected by Inflammatory Bowel Disease (IBD) focuses on comorbidity with psychiatric disorders, somatization or alexithymia. Whereas IBD patients had higher risk of stable anxiety and depression for many years after the diagnosis of the disease, there is a lack of studies reporting a comprehensive psychosomatic assessment addressing factors of disease vulnerability, also in the long-term. The objective of this investigation is to fill this gap in the current literature. The aims were thus to assess: a) changes between baseline and a 4-year follow-up in psychiatric diagnoses (SCID), psychosomatic syndromes (DCPR), psychological well-being (PWB-I), lifestyle, gastrointestinal symptoms related to IBD and Irritable Bowel Syndrome (IBS)-like symptoms b) stability of psychiatric and psychosomatic syndromes at 4-year follow-up. A total of 111 IBD outpatients were enrolled; 59.5% of them participated at the follow-up. A comprehensive assessment, including both interviews and self-report questionnaires, was provided at baseline and follow-up. Results showed increased psychiatric diagnoses, physical activity, consumption of vegetables and IBS-like symptoms at follow-up. Additionally, whereas psychiatric diagnoses were no longer present and new psychopathological pictures ensued at follow-up, more than half of the sample maintained psychosomatic syndromes (particularly allostatic overload, type A behavior, demoralization) from baseline to follow-up. Long-term presence/persistence of such psychosocial burden indicates the need for integrating a comprehensive psychosomatic evaluation beyond traditional psychiatric nosography in IBD patients. Moreover, since psychosomatic syndromes represent vulnerability factors of diseases, further studies should target subgroups of patients presenting with persistent psychosomatic syndromes and worse course of the disease.

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Introduction

Inflammatory Bowel Diseases (IBD), including ulcerative colitis (UC) and Crohn's disease (CD), are chronic diseases that exhibit an unpredictable clinical course, with alternating active phases and periods of variable duration of remission [ 1 , 2 ]. The epidemiology of IBD is rapidly changing worldwide. The estimated prevalence continues to rise in Western countries, with a high burden of IBD in North America, Oceania, and Europe [ 3 ], reaching approximately 2.2 million of IBD patients in USA [ 4 ]. In Northern Italy, the average incidence of IBD registered in the period 2016–2021 was 18 per 100.000 inhabitants/year [ 5 ]. IBD specific symptoms are fever, weight and appetite loss, bloody stool, vomiting and anemia [ 6 , 7 ]. A high percentage of other symptoms such as abdominal pain, bloating, diarrhea and watery stools, transversally exhibited in IBD and Irritable Bowel Syndrome (IBS) patients are reported. IBD may be complicated by extra-intestinal systemic manifestations such as rheumatological, ocular, dermatological, hepatobiliary, pulmonary, cardiac, and hematological [ 8 ]. There is also an increased risk of neoplasms, mainly colorectal [ 9 ]. An intimate connection between the central nervous and the enteric nervous systems (gut-brain axis) was observed [ 10 ]. Indeed, psychiatric comorbidity in IBD is well known and higher than in matched cohorts [ 11 , 12 ]. It is increasingly acknowledged that both psychological and biological pathways play a role in stress-induced alterations in IBD expression [ 13 ]. On the one hand, psychiatric disorders such as anxiety and depressive disorders may trigger and exacerbate intestinal inflammation or contribute to relapse [ 14 , 15 ]. On the other hand, both active physical symptoms and the chronic and severe nature of IBD can negatively impact an individual's mental health [ 16 , 17 ]. Furthermore, subclinical manifestations, such as somatization [ 18 ] and alexithymia [ 19 ], affecting IBD patients’ clinical disease activity [ 18 ] and quality of life [ 20 , 21 ] were observed. In IBD patients, healthy lifestyle such as regular physical exercise [ 22 ], a personalized dietary approach, [ 23 ], avoidance of smoking [ 24 , 25 ] and light or no alcohol consumption [ 26 ] are recommended. However, some of these recommendations are contrary to what is often practiced by IBD patients [ 27 ]. Whereas Bisgaard and colleagues [ 28 ] found that patients with IBD had higher risk of anxiety and depression starting at least five years before and continuing until at least ten years after IBD diagnosis, there is a lack of studies reporting a comprehensive psychosomatic assessment, addressing different factors of disease vulnerability in IBD patients, also in the long-term, despite the advocated need for a thorough evaluation and management of IBD [ 28 ]. In order to fill the gaps in the existing literature, the present study aimed to conduct a more extensive investigation of the clinical and subclinical psychological profile of IBD outpatients at baseline and at a 4-year follow-up. Additionally, our study aimed to verify the long-term stability of psychosomatic syndromes in IBD patients. Specifically, the present study had two objectives: a) to assess changes between baseline and a 4-year follow-up in psychiatric profile according to DSM-5 [ 29 ], psychosomatic syndromes on the basis of Diagnostic Criteria for Psychosomatic Research (DCPR) [ 30 ], psychological well-being (PWB) according to PWB-Interview (PWB-I) [ 31 ] and lifestyle, as well as in IBD-related symptoms and IBS-like symptoms b) to assess the stability of psychiatric and psychosomatic syndromes at 4-year follow-up.

Participants and procedure

Consecutive outpatients with IBD in remission phase, including Crohn’s disease and ulcerative colitis, were recruited at the Unit of Gastroenterology of Local Unit Health (AUSL) of Bologna (Italy), after a check-up visit. The diagnosis of CD and UC were based on clinical history, blood and fecal tests, endoscopic, histologic and radiologic findings, following the ECCO-ESGAR Guidelines [ 32 , 33 ].

Patients were recruited at baseline between December 2018 and January 2020. After the check-up visit, patients were asked to join the study and the informed consent document was provided. The interview was conducted soon after obtaining patients’ written informed consent. Participants were subsequently contacted again, approximately four years later, to set an appointment for the follow-up interview, which was conducted by phone. The local ethics committee approved the longitudinal study. All procedures involved in the present investigation adhere to the ethical standards set by the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.

The interviews followed the same procedure at baseline and follow-up. Patients were assessed by three clinical psychologists trained to conduct the interviews. During the baseline assessment, patients underwent face-to-face interviews, whereas, during the follow-up, interviews were conducted via telephone. At both assessments, sociodemographic data, including gender, age, education level, occupation, marital status were collected, as well as regularly taken medications.

Participants underwent three validated clinical interviews for the assessment of psychiatric disorders, psychosomatic syndromes and psychological well-being. Information about lifestyle such as physical activity, diet, alcohol consumption, and smoking were collected as well. Additional ad hoc questions about the presence of IBD related symptoms and IBS-like symptoms were introduced. On average, the interview lasted 45 minutes.

• Psychiatric diagnoses

The Italian adaptation [ 34 ] of the Structured Clinical Interview for DSM-5, clinician version (SCID-5-CV) [ 29 , 35 ], to assess the presence of various psychiatric conditions, including depressive disorders (major depression), anxiety disorders (panic disorder, generalized anxiety disorder, agoraphobia and social anxiety), eating disorders (bulimia, binge eating disorder, and anorexia nervosa), and other disorders such as obsessive-compulsive disorder, somatic symptom disorders and illness anxiety, was employed. Moreover, current minor depression from the DSM-IV-TR appendix was assessed [ 36 ]. The SCID-5-CV demonstrated exceptional reliability, notable specificity, and clinical validity [ 37 ]. These findings substantiate its utility and appropriateness for routine clinical application [ 38 ].

• Psychosomatic syndromes

The Italian version of the Semi-Structured Interview, which is based on the revised Diagnostic Criteria for Psychosomatic Research (DCPR-R) [ 30 ], was employed for the identification of psychosomatic syndromes. The updated version of DCPR was developed based on insights derived from its extensive use in many patients and various clinical settings [ 39 , 40 ], encompassing diagnostic criteria for two additional syndromes such as allostatic overload and hypochondriasis. The interview protocol, grounded in DCPR-R, has already demonstrated its utility within medical settings [ 41 ]. It comprises a set of dichotomous (yes or no) items, complemented with screening questions that refer to the essential criteria of the disorders. This assessment instrument enables the examination of psychosomatic syndromes, which are delineated into four distinct domains: stress, personality, illness behavior, and psychological manifestations [ 30 ]. The stress domain includes allostatic overload. In the personality domain, type A behavior and alexithymia are considered. Illness behavior encompasses hypochondriasis, disease phobia, thanatophobia, health anxiety, persistent somatization, conversion symptoms, anniversary reaction and illness denial. The cluster regarding the psychological manifestations covers demoralization, demoralization with hopelessness, irritable mood and somatic symptoms secondary to a psychiatric disorder [ 30 ]. These criteria have been meticulously developed with the aim of operationalizing the spectrum of manifestations of illness behavior and sub-threshold distress within both psychiatric and medical contexts. They can be utilized independently of, or in conjunction with, the DSM criteria [ 42 ]. The interview has demonstrated excellent interrater reliability, construct validity, and predictive validity concerning psychosocial functioning and treatment outcomes [ 43 , 44 ].

• Psychological well-being

The Italian version (PWB-I) [ 31 ] of the semi-structured interview based on the Psychological Well-Being (PWB) scales items [ 45 ] was employed. This instrument was utilized to evaluate the psychological well-being and resilience of individuals in clinical populations, aligning with the multidimensional model proposed by Ryff [ 45 ]. The original version of the PWB scale has exhibited favorable psychometric properties, including robust internal consistency [ 46 ] and this adaptation shows test-retest reliability in prior research endeavors [ 31 ]. It was used to facilitate tailoring of interventions and support strategies to address specific psychological needs of patients affected by IBD. The adapted questionnaire consists of 18 questions, in which respondents are asked to provide dichotomous responses in the form of "Yes" or "No" to each of these questions that encompass the six fundamental dimensions of PWB (environmental mastery, personal growth, purpose in life, autonomy, self-acceptance and positive relationship with others) as conceptualized by Ryff [ 45 ].

Lifestyle-related behaviors

An adapted version of the GOSPEL questionnaire to assess lifestyle-related behaviors [ 47 , 48 ] was used. This particular adaptation was specifically crafted to surmount the inherent limitations posed by comprehensive questionnaires typically employed for the evaluation of dietary habits and leisure time physical activity. The assessment instrument is multifaceted and includes lifestyle dimensions such as physical activity, dietary habits (vegetables, fruits, fish and dairy products consumption), alcohol consumption and tobacco smoking. Respondents were asked to rate their habits on a 4-point Likert scale, indicating the frequency of each specific habit per week. This measure is frequently well-suited for real-world clinical environments marked by time limitations and practical constraints [ 47 , 48 ]. This modified questionnaire has demonstrated its efficacy in previous investigations focused on patients affected by various medical conditions [ 49 , 50 ].

IBD-related symptoms, IBS-like symptoms

In order to assess IBD-related symptoms (fecal blood) and IBS-like symptoms (e.g. constipation/diarrhea, mild abdominal pain, bloating) both at baseline and follow-up, five ad hoc questions were asked.

Data analysis

Data were entered into SPSS 20.0 for Windows (SPSS Inc., Chicago, IL, USA). Descriptive analyses were used to outline socio-demographic data, pharmacological treatment, psychiatric/psychosomatic diagnoses (DSM-5 and DCPR-R), well-being scores (PWB-I), lifestyle-related behaviors, IBD symptoms and IBS-like symptoms of the sample both at baseline and follow-up. Normal distribution of data was assessed with Shapiro-Wilk test and, when not confirmed ( p < .05), median and interquartile range was reported.

For both first and second aim, analyses were conducted on the subgroup of patients who underwent follow-up assessment.

Regarding the first aim, differences in the frequencies of current psychiatric diagnoses (DSM) and psychosomatic syndromes (DCPR) between baseline and follow-up were evaluated using the McNemar test. Wilcoxon signed-rank test was applied to underline differences between the number of DCPR syndromes and the number of SCID diagnoses at baseline and follow-up. Next, differences in well-being scores (PWB-I) and lifestyle-related behaviors from baseline to follow-up, were studied using the Sign test. Additionally, to assess differences in the distribution of smokers and non-smokers between baseline and follow-up, a McNemar test was employed. Finally, a McNemar test with the aim of comparing the presence of IBD related and IBS-like symptoms in the two evaluations was applied.

Regarding the second aim, to determine which DSM and DCPR diagnoses were maintained between baseline and follow-up, contingency tables were used. Significance level for all the analyses was set to 0.05, two-tailed.

At baseline, the sample consisted of 111 patients: 44 males (39.6%) and 67 females (60.4%). The distribution of age ( W = .974, p = .029) and duration of the disease ( W = .895, p < .001) did not approximate a normal distribution. Patients had a median age of 49 years ( IQR = 22) and have been living with the disease for a median of 9 years ( IQR = 12).

Out of the 111 patients contacted to be assessed in the follow-up study, 59.5% agreed to participate. 36.4% were males and 63.6% females. The distribution of age ( W = .963, p = .044) and duration of the disease ( W = .863, p <.001) did not approximate a normal distribution. Participants had a median age of 50 years ( IQR = 23) and have been living with the disease for a median of 13 years ( IQR = 12). Out of the 111 patients, 45 (40.5%) did not participate due to time constraints (33.4%) and inability to be contacted (6%); among them, 20 (44.4%) were males and 25 (55.6%) females with a mean age (W = .967, p =.217) of 55.3 years ( SD = 13.20). Patients’ sociodemographic data and pharmacological treatment of baseline and follow-up are described in Table 1 .

Regarding the first aim of the study, the frequency of DSM diagnoses from baseline to follow-up showed a significant increase ( p < .001). Indeed, 6.1% of IBD patients presented with DSM diagnoses at baseline, whereas 31.8% at follow-up (frequencies associated with each diagnosis, both at the baseline and follow-up assessments, are delineated in Table 2 ).

Regarding psychosomatic syndromes, the frequency of DCPR diagnoses between baseline and follow-up did not show a significant increase ( p = . 086 ). 71.2% of IBD patients presented at least one DCPR syndrome at baseline, whereas 75.5% at follow-up. The only significant change was the increase in persistent somatization: 6.06% at baseline and 24.24% at follow-up ( p = .008) (Table 2 ).

No significant results emerged from the comparisons of PWB-I scores between baseline and follow-up (Table 3 ) .

The analysis of lifestyle-related behaviors showed few significant differences between baseline and follow-up. In particular, the frequency of physical activity ( Z = - 2.09, p = .037) and the consumption of vegetables ( Z = - 2.96, p = .003) increased, while no significant changes between baseline and follow-up were observed for the remaining habits. Lifestyle data and comparisons are reported in Table 4 .

Concerning IBD related symptoms, results did not show any significant change. 7.6% presented IBD related symptoms at baseline, whereas 16.7% at follow-up (no one maintained these symptoms). About IBS-like symptoms, patients showed a significant increase between baseline and follow-up ( p < .001). Indeed, 9.1% at baseline presented IBS-like symptoms, whereas 56.1% at follow-up (4.5% maintained the symptoms) (Table 5 ).

Regarding the second aim, 1.5% of the sample maintained at least one DSM diagnosis and 30.3% developed new DSM diagnoses. On the contrary, the percentage of IBD patients who maintained at least one DCPR syndrome was 54.5% whereas 21.2% developed new DCPR syndromes. The DCPR syndromes that were found to persist to some extent in IBD patients were allostatic overload (19.7% of the total sample), type A behavior (16.7%), alexithymia (7.6%), and demoralization (7.6%) (Table 2 ). In particular, the DCPR syndromes that persisted in more than half of the cases from baseline to follow-up were allostatic overload, Type A behavior and demoralization (Table 2 ).

The current study aimed to conduct an integrated assessment approach that encompasses the clinical and subclinical psychological profile of IBD outpatients in a longitudinal perspective, in order to provide a more comprehensive characterization of IBD patients.

Regarding psychiatric diagnoses, findings of the present study revealed a significant increase at follow-up, as only 4 (6.1%) patients had at least one DSM diagnosis at baseline, whereas 21 (31.8%) at follow-up. Among the most commonly observed diagnoses at follow-up, minor depression and generalized anxiety disorder were detected. Indeed, it was reported that anxiety and depressive disorders are prevalent [ 51 ] and can affect patients’ quality of life, as well as the course of IBD [ 52 ]. Moreover, in a review by Arp and colleagues [ 53 ] the prevalence of psychiatric comorbidities was high in patients with IBD and higher than in the background population. Further, a retrospective study by Marrie and colleagues [ 11 ] reported that individuals with Immune Mediated Inflammatory Disease (IMID), including IBD, have a non-specifically increased risk of psychiatric comorbidity with a cumulative incidence of depression of 20% five years after the IBD diagnosis.

About psychosomatic syndromes, the majority of the sample both at baseline and follow-up (71.2% and 75.5%, respectively) presented at least one DCPR syndrome. Among them, allostatic overload, alexithymia, type A behavior and demoralization were frequently observed both at baseline and follow-up in IBD patients, whereas persistent somatization was the only DCPR syndrome increased at follow-up. It is well known the relevance of the DCPR system in detecting psychological distress in medical disease settings, in comparison or integrated with the current psychiatric system. Indeed, DCPR syndromes were found to be transversally represented in most medical settings [ 39 ], even though in IBD patients had never been described. From the present study findings, it seems that more than a quarter of IBD patients present with allostatic overload, alexithymia or Type A behavior, both at baseline and follow-up. Patients with allostatic overload are thus characterized by feelings of being overwhelmed by the demands of daily life and may also present sleep disturbances, irritability, impaired social or occupational functioning [ 30 ]. Psychological stress has long been reported anecdotally to increase disease activity in IBD. Studies have confirmed that adverse life events and chronic stress increase the likelihood of relapse in patients with quiescent IBD [ 54 ]. IBD patients with alexithymia are inhibited concerning the experience and expression of emotions and show difficulties in communication [ 30 ]. Elevated levels of alexithymia were commonly observed in patients with IBD, especially in females [ 55 ], and this appeared to be associated with an increased likelihood of experiencing unfavorable clinical outcomes [ 19 , 20 ]. IBD patients with Type A behavior are characterized by impatience and a sense of time-related pressure, irritability, and a competitive drive. The high frequency of Type A behavior in IBD patients and not only in cardiology settings, suggests that it might be considered as a relevant psychosomatic factor across a variety of clinical and preclinical conditions requiring a careful evaluation by clinicians [ 39 ]. Demoralized IBD patients present a feeling state characterized by their consciousness of having failed to meet their own expectations (or those of others) or being unable to cope with some pressing problems. Demoralized patients also experience prolonged and generalized feelings of helplessness. This phenomenon should not be ascribed to a normative reaction to stress or the presence of mood disorders in a subdued form [ 30 ]. In the literature, findings suggest a high prevalence of demoralization in the medically ill and the feasibility of a differentiation between demoralization and depression [ 56 ]. In the current study, the only diagnosis that had a significant increase at follow-up was persistent somatization. Indeed, 4 patients (6.1%) at baseline and 16 patients (24.2%) at follow-up presented this syndrome. Patients presenting persistent somatization complain about functional symptoms, such as IBS-like symptoms, causing distress, repeated medical care or impaired quality of life; they also exhibit additional symptoms of autonomic arousal also involving other organ systems and exaggerated side effects from medical therapy, indicating low sensations or pain thresholds and high suggestibility [ 30 ]. Consistently with the tendency of these patients to have difficulties expressing psychological distress, leading to its translation into physical symptoms, psychological comorbidity including somatization and perceived stress were found to be common in IBD [ 57 , 58 ].

The comparison of well-being scores, as measured by the PWB-I at baseline and follow-up, did not show any significant results. However, in comparison with the PWB-I scores of a screening population for fecal occult blood test in a study conducted by Gostoli and colleagues [ 59 ], in the present investigation, the PWB-I scores of IBD patients without DCPR syndromes were similar to those of the screening population without DCPR syndromes, whereas the PWB-I scores of IBD patients with DCPR syndromes were slightly lower than those of the screening population with DCPR syndromes.

Concerning lifestyle-related behaviors, a notable and statistically significant increase in physical activity and the consumption of vegetables was detected. This could be the result of healthy lifestyle promoting prescriptions given by the gastroenterologist during the scheduled visits and followed by the patients, contrary to the literature contributions, which instead reported IBD patients’ difficulty in adhering to them [ 27 ]. It has been reported that physical activity represents a protective factor against IBD [ 22 ]. The literature also provides some guidelines on the optimal diet for these patients, suggesting that low-fiber diets may encourage intestinal inflammation, while high-fiber diets may provide protection against the inflammatory process [ 60 ]. In the present study, other healthy lifestyle behaviors were maintained, probably because most patients had been living with the disease for many years, before the first assessment, and thus they might have already adjusted some aspects of their habits. Consequently, at follow-up, the majority have continued to uphold these changes. This finding is in contrast with the study by Lo et al. [ 27 ], where IBD outpatients were found to not practice such recommendations. As said before, it is likely that the gastroenterologists involved in the present study posed a great attention on healthy lifestyle.

Concerning the IBD related symptoms and IBS-like symptoms, whilst nearly all the patients were asymptomatic at baseline, only IBS-like symptoms such as abdominal pain, bloating, diarrhea and watery stools showed a significant increase after 4-year follow-up. On the same line, contributions in literature showed a higher prevalence of IBS-like symptoms in patients with IBD than in the general population [ 61 ]. Such symptoms were associated with psychological comorbidity, such as anxiety and depression [ 62 ]. According to Spiller and Major [ 63 ], a dysregulated interaction between peripheral factors (i.e., microbiota and post-inflammatory changes) and central factors (stress, psychological comorbidity), might generate such gastrointestinal symptoms. Furthermore, in the present study, findings of increased persistent somatization at follow-up might result in a higher burden of IBS-like symptoms.

Regarding the second aim, it was observed that only 1.5% of the IBD patients maintained at least one DSM diagnosis, despite in the literature Bisgaard and colleagues [ 28 ] found that patients with IBD had higher risk of anxiety and depression continuing until at least ten years after IBD diagnosis. On the other hand, our findings showed that more than half of the patients maintained psychosomatic syndromes between baseline and follow-up. The most stable DCPR syndromes included allostatic overload, type A behavior and demoralization. To the best of our knowledge, there is a lack of literature specifically addressing this topic but there are some notable contributions in other medical settings. For example, patients with post-coronary artery bypass grafting and those with Implantable Cardioverter Defibrillators (ICD) showed sustained DCPR syndromes over time. The 1-month and 6/8-year post-surgery assessments for bypass patients confirmed stability in type A behavior, irritable mood, demoralization and persistent somatization [ 64 ]. The latter syndromes persisted over a year in ICD patients [ 65 ]. In line with our findings, DCPR categories remained stable in individuals over time in both cases. The stability of DCPR syndromes might as well have resulted in increased burden of IBS-like symptoms along the follow-up period, as previously described. Moreover, unlike depression, demoralization was found to rarely persist as an uninterrupted condition for any substantial duration, in different medical settings (e.g., gastroenterology, cardiology, endocrinology, and oncology) [ 66 ]. However, this is in contrast with the findings of the present study, where more than half of the patients affected by demoralization at baseline presented with persistent demoralization at follow-up.

The current study shows some limitations such as small sample size, absence of a control group, distinction between IBD- and IBS-like symptoms not always possible and data collection method, which changed between the initial and follow-up assessments. Indeed, during the baseline assessment, interviews were performed face-to-face, while follow-up assessments were conducted over the phone. This variation in data collection methods might have introduced factors such as participants’ fatigue, especially given the overall length of the interviews, potentially leading to less attentive responses. In addition, the telephone-based approach and the absence of in-person contact could have influenced the relationship between the interviewer and the patients, especially with older participants.

Despite the mentioned limitations, the strengths of this study include the presence of a comprehensive assessment of clinical and sub-clinical aspects of IBD patients, the longitudinal design of the study and the use of measure according to clinimetric validity.

These longitudinal study findings revealed clinical and persistent subclinical distress in a sample of IBD outpatients longitudinally assessed. It seems that, whereas psychiatric conditions are more changeable over time, psychosomatic syndromes such as allostatic overload, type A behavior, alexithymia and demoralization represent persistent unhealthy attitudes in IBD patients at a long-term follow. These findings, together with the development of persistent somatization at follow-up, might have an impact on the increase of IBS-like symptoms, whereas after 4-year follow-up IBD symptoms were managed. Since it has been advocated the need for a comprehensive assessment and management of IBD, in order to develop more targeted treatment, an integrated assessment through the DCPR system enables the identification of subclinical aspects not detected by traditional tools, as vulnerability factors of the disease. From a secondary prevention perspective, studying the persistence over time of certain DCPR syndromes in patients with IBD could be useful to monitor the psychophysical conditions of IBD patients.

Availability of data and materials

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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S.G.: conceptualization and methodology, validation, visualization, writing—original draft, writing—review and editing; F.F.: conceptualization and methodology, validation, resources, project administration, writing—review and editing; L.Q.: validation, formal analysis, investigation, data curation, visualization, writing—original draft, writing—review and editing; S.T.: validation, formal analysis, investigation, data curation, visualization, writing—original draft, writing—review and editing; G.G.: formal analysis, writing—review and editing; M.M.: resources; A.U.: resources; F.G.: formal analysis, writing—review and editing; R.S.: writing—review and editing; A.D.: visualization, writing—review and editing; A.P.: resources, writing—review and editing; F.B.: resources, writing—review and editing; V.C.: supervision, resources, writing—review and editing; C.R.: conceptualization and methodology, validation, visualization, supervision, project administration, writing—original draft, writing—review and editing.

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Gostoli, S., Ferrara, F., Quintavalle, L. et al. Four-year follow-up of psychiatric and psychosomatic profile in patients with Inflammatory Bowel Disease (IBD). BMC Psychol 12 , 211 (2024). https://doi.org/10.1186/s40359-024-01726-5

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ORIGINAL RESEARCH article

Hyperhomocysteinemia is associated with the risk of venous thromboembolism in patients with mental illness ： a case-control study.

• 1 Department of Pulmonary and Critical Care Medicine, Zhejiang Taizhou Hospital, Taizhou, China
• 2 Department of Pulmonary and Critical Care Medicine,Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou，Zhejiang, China
• 3 Department of Mental Health, Sir Run Run Shaw Hospital, School of Medicine, Graduate School, Zhejiang University, Hangzhou, Jiangsu Province, China

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Objective: The risk of venous thromboembolism in patients with mental illness has been insufficiently addressed. This study aimed to assess the correlation between hyperhomocysteinemia and venous thromboembolism prevalence among this population.Methods: Patients with a diagnosis of mental illness and concurrent venous thromboembolism, admitted to Sir Run Run Shaw Hospital at Zhejiang University School of Medicine between January 2014 and December 2021, were included in the venous thromboembolism group. The control group, approximately twice the size, comprised individuals with mental illness but without venous thromboembolism.Basic clinical data were gathered for both cohorts.Results: In psychiatric patients, elevated D-dimer levels(OR=5.60,95% CI 3.28-10.00), hyperhomocysteinemia (OR=2.37 ,95% CI 1.10-5.14), and hyperprolactinemia(OR= 2.68 ,95% CI 1.12-6.42)were significant risk factors for venous thromboembolism. According to further subgroup analyses, hyperhomocysteinemia is a significant risk factor associated with pulmonary embolism, with an OR of 5.08 (95% CI 1. 20-21.48). An interaction effect between gender and homocysteine level was found, with a p-interaction of 0.022. A subsequent analysis confirmed the association between hyperhomocysteinemia and venous thromboembolism in female psychiatric patients, with an OR of 3.34 (95% CI 1.68-6.65), indicating that hyperhomocysteinemia is a significant risk factor for venous thromboembolism in women.Conclusion: Patients with psychiatric disorders were found to have an elevated risk of venous thromboembolism, which was associated with increased levels of D-dimer, hyperprolactinemia, and hyperhomocysteinemia. A strong correlation between hyperhomocysteinemia and pulmonary embolism was identified in patients with mental illnesses. Furthermore, the study revealed that female psychiatric patients with hyperhomocysteinemia constituted a high-risk group for venous thromboembolism. This finding holds significant clinical implications, suggesting that early preventative measures could be implemented for this high-risk population to reduce the incidence of thromboembolic events during hospitalization for psychiatric patients.

Keywords: mental illness, Venous Thromboembolism, Hyperhomocysteinemia, Hyperprolactinemia, pulmonary thromboembolism

Received: 17 Nov 2023; Accepted: 29 Apr 2024.

Copyright: © 2024 Wang, Zhang, Ren, Li and Ying. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: Kejing Ying, Department of Pulmonary and Critical Care Medicine,Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou，Zhejiang, China

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Research: More People Use Mental Health Benefits When They Hear That Colleagues Use Them Too

• Laura M. Giurge,
• Lauren C. Howe,
• Zsofia Belovai,
• Guusje Lindemann,
• Sharon O’Connor

A study of 2,400 Novartis employees around the world found that simply hearing about others’ struggles can normalize accessing support at work.

Novartis has trained more than 1,000 employees as Mental Health First Aiders to offer peer-to-peer support for their colleagues. While employees were eager for the training, uptake of the program remains low. To understand why, a team of researchers conducted a randomized controlled trial with 2,400 Novartis employees who worked in the UK, Ireland, India, and Malaysia. Employees were shown one of six framings that were designed to overcome two key barriers: privacy concerns and usage concerns. They found that employees who read a story about their colleague using the service were more likely to sign up to learn more about the program, and that emphasizing the anonymity of the program did not seem to have an impact. Their findings suggest that one way to encourage employees to make use of existing mental health resources is by creating a supportive culture that embraces sharing about mental health challenges at work.

“I almost scheduled an appointment about a dozen times. But no, in the end I never went. I just wasn’t sure if my problems were big enough to warrant help and I didn’t want to take up someone else’s time unnecessarily.”

• Laura M. Giurge is an assistant professor at the London School of Economics, and a faculty affiliate at London Business School. Her research focuses on time and boundaries in organizations, workplace well-being, and the future of work. She is also passionate about translating research to the broader public through interactive and creative keynote talks, workshops, and coaching. Follow her on LinkedIn  here .
• Lauren C. Howe is an assistant professor in management at the University of Zurich. As head of research at the Center for Leadership in the Future of Work , she focuses on how human aspects, such as mindsets, socioemotional skills, and leadership, play a role in the changing world of work.
• Zsofia Belovai is a behavioral science lead for the organizational performance research practice at MoreThanNow, focusing on exploring how employee welfare can drive KPIs.
• Guusje Lindemann is a senior behavioral scientist at MoreThanNow, in the social impact and organizational performance practices, working on making the workplace better for all.
• Sharon O’Connor is the global employee wellbeing lead at Novartis. She is a founding member of the Wellbeing Executives Council of The Conference Board, and a guest lecturer on the Workplace Wellness postgraduate certificate at Trinity College Dublin.

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Neuroimaging, AI help detect brain changes

Uc researchers co-lead nimh-funded study of children of bipolar parents.

Researchers at the University of Cincinnati and Dell Medical School at the University of Texas at Austin (Dell Med) are leading a study using state-of-the-art neuroimaging techniques and artificial intelligence to identify changes in the brains among children of adults living with bipolar disorder — a debilitating condition that interferes with daily life due to its dramatic mood, energy and activity level shifts. 

Almost 3% of U.S. adults live with bipolar disorder, one of the leading causes of disability worldwide. The highest risk factor for bipolar disorder is having a close family member with the condition.  

The study is co-led by UC’s Melissa DelBello, MD; Jorge Almeida, MD, and Charles Nemeroff, MD, PhD of Dell Med and Indiana University’s Stephen Strakowski, MD. 

Melissa DelBello, MD. Photo/University of Cincinnati.

“We are hoping to clarify how stress and trauma impact brain development in children and adolescents who have a family risk for bipolar disorder,” said DelBello, the Dr. Stanley and Mickey Kaplan Endowed Chair and Professor in the Department of Psychiatry and Behavioral Neuroscience at UC’s College of Medicine. “This work is the next step in studying risk and resilience factors associated with bipolar disorder.”   

The brain’s inability to “hit the brakes” on energy delivered by its reward system results in manic behaviors such as spending too much money, engaging in risky behaviors and sleep loss or disruption, said Almeida, director of the Bipolar Disorder Center at Mulva Clinic for the Neurosciences and associate professor in the Department of Psychiatry and Behavioral Sciences at Dell Med.  

The study is the first of its kind to focus specifically on the progression of the disease over time via neuroimaging in children of parents with bipolar disorder. 

The research leverages AI algorithms to discern variations in participants’ brains, combining imaging data with cognitive, clinical, early life adversity and psychosocial function measures. The result is a precise delineation of brain maturation for each person at risk of developing bipolar disorder. 

This study will increase our understanding of the onset of bipolar disorder and ultimately help us identify effective strategies to intervene early or prevent the onset of the illness.

Melissa DelBello, MD

The five-year longitudinal study uses functional magnetic resonance imaging to identify early signs that the brain is developing bipolar disorder. Participants ages 14-21 — a critical time when mania symptoms often develop — undergo annual brain scans to track changes in the brain. If they become depressed, suicidal or experience mania, the participants undergo additional brain scans to help researchers understand how the damage is unfolding. 

Participants also undergo mood assessments and are required to perform tasks that activate and test the brain’s reward system. 

“This study will increase our understanding of the onset of bipolar disorder and ultimately help us identify effective strategies to intervene early or prevent the onset of the illness,” DelBello said. 

“This study evokes hope for me,” Almeida said. “Hope that we finally have the tools to help this condition and possibly prevent it from ever happening.”  

Impact Lives Here

The University of Cincinnati is leading public urban universities into a new era of innovation and impact. Our faculty, staff and students are saving lives, changing outcomes and bending the future in our city's direction.  Next Lives Here.

In its third year of a five-year grant, the research is funded by the National Institute of Mental Health. Additional investigators on the project at UC include David Fleck, PhD, Kelly Cohen, PhD, Cal Adler, MD, and L Rodrigo Patino Duran, MD.  

A version of this story was first published in the Dell Med newsroom .

Featured photo at top of brain scans. Photo/Nur Ceren Demir/iStock.

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Researchers at the University of Cincinnati and Dell Medical School at the University of Texas at Austin are leading a study using state-of-the-art neuroimaging techniques and artificial intelligence to identify changes in the brains among children of adults living with bipolar disorder.

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October 31, 2023

U.S. News & World Report highlighted recent research led by the University of Cincinnati and Northwell Health that found the drug metformin can help prevent or reduce weight gain in youth taking medication to treat bipolar disorder.

• Open access
• Published: 26 April 2024

Clinician and staff experiences with frustrated patients during an electronic health record transition: a qualitative case study

• Sherry L. Ball 1 ,
• Bo Kim 2 , 3 ,
• Sarah L. Cutrona 4 , 5 ,
• Brianne K. Molloy-Paolillo 4 ,
• Ellen Ahlness 6 ,
• Megan Moldestad 6 ,
• George Sayre 6 , 7 &
• Seppo T. Rinne 2 , 8  

BMC Health Services Research volume  24 , Article number:  535 ( 2024 ) Cite this article

82 Accesses

Metrics details

Electronic health record (EHR) transitions are known to be highly disruptive, can drastically impact clinician and staff experiences, and may influence patients’ experiences using the electronic patient portal. Clinicians and staff can gain insights into patient experiences and be influenced by what they see and hear from patients. Through the lens of an emergency preparedness framework, we examined clinician and staff reactions to and perceptions of their patients’ experiences with the portal during an EHR transition at the Department of Veterans Affairs (VA).

This qualitative case study was situated within a larger multi-methods evaluation of the EHR transition. We conducted a total of 122 interviews with 30 clinicians and staff across disciplines at the initial VA EHR transition site before, immediately after, and up to 12 months after go-live (September 2020-November 2021). Interview transcripts were coded using a priori and emergent codes. The coded text segments relevant to patient experience and clinician interactions with patients were extracted and analyzed to identify themes. For each theme, recommendations were defined based on each stage of an emergency preparedness framework (mitigate, prepare, respond, recover).

In post-go-live interviews participants expressed concerns about the reliability of communicating with their patients via secure messaging within the new EHR portal. Participants felt ill-equipped to field patients’ questions and frustrations navigating the new portal. Participants learned that patients experienced difficulties learning to use and accessing the portal; when unsuccessful, some had difficulties obtaining medication refills via the portal and used the call center as an alternative. However, long telephone wait times provoked patients to walk into the clinic for care, often frustrated and without an appointment. Patients needing increased in-person attention heightened participants’ daily workload and their concern for patients’ well-being. Recommendations for each theme fit within a stage of the emergency preparedness framework.

Conclusions

Application of an emergency preparedness framework to EHR transitions could help address the concerns raised by the participants, (1) mitigating disruptions by identifying at-risk patients before the transition, (2) preparing end-users by disseminating patient-centered informational resources, (3) responding by building capacity for disrupted services, and (4) recovering by monitoring integrity of the new portal function.

Peer Review reports

Electronic health record (EHR) transitions present significant challenges for healthcare clinicians and staff. These transitions require adjustments in care delivery and may threaten care quality and value. It is critical that healthcare organizations undergoing these changes learn from others who have undergone similar transitions [ 1 , 2 ]. However, the current literature lacks adequate guidance on navigating EHR transitions, especially as they relate to how clinicians and staff interact with patients [ 3 ].

Embedded within EHRs, patient portals facilitate complete, accurate, timely, and unambiguous exchange of information between patients and healthcare workers [ 4 , 5 ]. These portals have become indispensable for completing routine out-of-office-visit tasks, such as medication refills, communicating laboratory results, and addressing patient questions [ 6 ]. In 2003, the VA launched their version of a patient portal, myHealtheVet [ 7 ] and by 2017 69% of Veterans enrolled in healthcare at the VA had registered to access the patient portal [ 8 ]. Similar to other electronic portals, this system allows Veterans to review test results, see upcoming appointments, and communicate privately and securely with their healthcare providers.

EHR transitions can introduce disruptions to patient portal communication that may compromise portal reliability, impacting patient and clinician satisfaction, patients’ active involvement in self-management, and ultimately health outcomes [ 9 ]. During an EHR transition, patients can expect reductions in access to care even when clinician capacity and IT support are increased. Patients will likely need for more assistance navigating the patient portal including and using the portal to communicate with their providers [ 10 ]. Staff must be prepared and understand how the changes in the EHR will affect patients and safeguards must be in place to monitor systems for potential risks to patient safety. Building the capacity to respond to emerging system glitches and identified changes must be included in any transition plan. Although portal disruptions are likely to occur when a new EHR is implemented, we know little about how these disruptions impact healthcare workers’ interactions and care delivery to patients [ 11 , 12 ].

Due to an urgency to raise awareness and promote resolution of these patient portal issues,, we utilized existing data from the first EHR transition site for the Department of Veterans Affairs (VA)’s enterprise-wide transition. We focused on end users’ responses to the question “How Veterans were affected by the transition?”. We used qualitative methods to begin to understand how provider and patient interactions were affected during and by the EHR transition. We explored the impact of the EHR transition on patients through healthcare workers’ vicarious and direct experiences with patients. Due to the high level of disruption in care delivery we draw on insights from an emergency preparedness framework [ 13 ] to generate a set of recommendations to improve healthcare workers’ experiences during EHR transitions. The emergency preparedness framework includes 4 phases of an iterative cycle that include: (1) building capacity to mitigate issues, (2) preparing for the inevitable onset of issues, (3) responding to issues as they emerge, and (4) strategies to recover from any damage incurred.

In early 2020, the VA embarked on an EHR transition from a homegrown, legacy EHR system, developed by VA clinicians and used since the 1990s, to a new commercial system by the Oracle-Cerner Corporation. The primary objectives of this transition were to standardize care and improve interoperability between VA Medical Centers nationwide and the Department of Defense (DoD). Spanning over a decade, this transition plan is scheduled to roll out to all VA medical centers and outpatient clinics.

In this manuscript, we present data from the Mann-Grandstaff VA Medical Center in Spokane, WA, VA’s first EHR transition site. The study uses qualitative methods with clinician and staff interviews as part of a larger multi-method evaluation of the EHR transition. Our overarching goal is to identify and share recommendations to improve VA’s EHR transition efforts; rather than be guided by a theoretical framework our study design including the interview guides [ 14 , 15 ] were based primarily on what was being experienced. An experienced team of ten qualitative methodologists and analysts conducted the study.

This evaluation was designated as non-research/quality improvement work by the VA Bedford Healthcare System Institutional Review Board deeming it exempt from needing an informed consent. Study materials, including interview guides with verbal consent procedures, were reviewed and approved by labor unions and by the VA Bedford Healthcare System Institutional Review Board; all methods were carried out in accordance with local and national VA guidelines and regulations.

Interview guides and an outline of the data collection plans were reviewed and approved by relevant national unions before beginning recruitment.

Recruitment

Recruitment began in July 2020, before the first site implemented the new EHR. Prior to collecting data, we met with site leadership to get buy-in and support for the study, understand local context, determine how the site was approaching the transition, and to obtain the names of clinicians and staff for potential interviews. All potential participants were invited by email to participate in a one-hour voluntary interview conducted on Microsoft Teams® about their experiences with this transition; we used snowball sampling during interviews to expand the pool of interviewees. Verbal permission for audio recording of interviews was obtained immediately prior to the interview. Interview participants were informed that they could skip any questions, pause or stop the recording, and stop the interview at any time and were invited to ask questions before beginning the interview.

Most participants were interviewed at multiple timepoints; these included pre-implementation interviews, brief check-ins, and post-implementation interviews (Table  1 ). At the end of the pre-implementation interview, participants were invited to participate in 3–4 additional, shorter (15–20 min), check-in interviews where information about any changes in the transition process, context, or experience could be discussed. Most initial interviewees, in addition to three new participants, participated in post-implementation interviews (35–60 min; approximately 2–3 months and 10–12 months after the implementation) to reflect on the entire transition process.

Data collection

Experienced qualitative interviewers included PhD trained qualitative methodologist and masters level qualitative analysts (JB, SB, AC, EK, MM, GS) conducted individual interviews with clinicians and staff, aligning to a semi-structured interview guide with follow-up probes using the participant’s words to elicit rich responses grounded in the data [ 16 ]. The guide was designed to inform ongoing efforts to improve the rollout of the new EHR. Six main categories were covered in our interview guides, including (1) attitudes toward the new software, (2) information communicated about the transition, (3) training and education, (4) resources, (5) prior experience with EHRs, and (6) prior experiences with EHR transitions. After piloting the interview guide with a clinician, initial interviews were completed between September and October 2020 and averaged  ∼  45 min in duration. Two-month and one-year post-implementation interview guides included an additional question, “Has the Cerner transition affected Vets?”; data presented here largely draw from responses to this question. Check-ins (October 2020– December 2020) took  ∼  15 min; two-month post-implementation interviews (December 2020– January 2021) and one-year post-implementation interviews (October 2020 - November 2021) took  ∼  45 min. Audio recordings of all interviews were professionally transcribed. To ensure consistency and relationship building, participants were scheduled with the same interviewer for the initial and subsequent interviews whenever feasible (i.e., check-ins and post-implementation interviews). Immediately following each interview, interviewers completed a debrief form where highlights and general reflections were noted.

Throughout the data collection process, interviewers met weekly with the entire qualitative team and the project principal investigators to discuss the recruitment process, interview guide development, and reflections on data collection. To provide timely feedback to leadership within the VA, a matrix analysis [ 17 ] was conducted concurrently with data collection using the following domains: training, roles, barriers, and facilitators. Based on these domains, the team developed categories and subcategories, which formed the foundation of an extensive codebook.

Data analysis

All interviewers also coded the data. We used inductive and deductive content analysis [ 18 ]. Interview transcripts were coded in ATLAS.ti qualitative data analysis software (version 9). A priori codes and categories (based on the overall larger project aims and interview guide questions) and emergent codes and categories were developed to capture concepts that did not fit existing codes or categories [ 18 ]. Codes related to patient experience and clinician interactions with patients were extracted and analyzed using qualitative content analysis to identify themes [ 18 ]. Themes were organized according to their fit within the discrete stages of an emergency preparedness framework to generate recommendations for future rollout. In total, we examined data from 111 interviews with 24 VA clinicians and staff (excluding the initial 11 stakeholder meetings (from the 122 total interviews) that were primarily for stakeholder engagement). We focused on participants’ responses related to their experiences interacting with patients during the EHR transition.

Exemplar quotes primarily came from participants’ responses to the question, “Has the Cerner transition affected Vets?” and addressed issues stemming from use of the patient portal. This included both clinicians’ direct experiences with the portal and indirect experiences when they heard from patients about disruptions when using the portal. We identified four themes related to clinicians’ and staff members’ reported experiences: (1) stress associated with the unreliability of routine portal functions and inaccurate migrated information; (2) concern about patients’ ability to learn to use a new portal (especially older patients and special populations); (3) frustration with apparent inadequate dissemination of patient informational materials along with their own lack of time and resources to educate patients on use of the new portal; and (4) burden of additional tasks on top of their daily workload when patients needed increased in-person attention due to issues with the portal.

Stress associated with the unreliability of routine portal functions and inaccurate migrated information

One participant described the portal changes as, “It’s our biggest stress, it’s the patients’ biggest stress… the vets are definitely frustrated; the clinicians are; so I would hope that would mean that behind the scenes somebody is working on it” (P5, check-in).

Participants expressed significant frustration when they encountered veterans who were suddenly unable to communicate with them using routine secure messaging. These experiences left them wondering whether messages sent to patients were received.

Those that use our secure messaging, which has now changed to My VA Health, or whatever it’s called, [have] difficulty navigating that. Some are able to get in and send the message. When we reply to them, they may or may not get the reply. Which I’ve actually asked one of our patients, ‘Did you get the reply that we took care of this?’ And he was like, ‘No, I did not (P11, 2-months post)

Participants learned that some patients were unable to send secure messages to their care team because the portal contained inaccurate or outdated appointment and primary site information.

I’ve heard people say that the appointments aren’t accurate in there… veterans who have said, ‘yeah, it shows I’m registered,’ and when they go into the new messaging system, it says they are part of a VA that they haven’t gone to in years, and that’s the only area they can message to, they can’t message to the [site] VA, even though that’s where they’ve actively being seen for a while now. (P20, 2-months post)

After the EHR transition, participants noted that obtaining medications through the portal, which was once a routine task, became unreliable. They expressed concern around patients’ ability to obtain their medications through the portal, primarily due to challenges with portal usability and incomplete migration of medication lists from the former to the new EHR.

I think it’s been negative, unfortunately. I try to stay optimistic when I talk to [patients], but they all seem to be all having continued difficulty with their medications, trying to properly reorder and get medications seems to still be a real hassle for them. (P17, one-year post) …the medications, their med list just didn’t transfer over into that list [preventing their ability to refill their medications]. (P13, 2-months post)

Concern about patients’ ability to learn to use a new portal

Clinicians and staff expressed concerns around veterans’ ability to access, learn, and navigate a new portal system. Clinicians noted that even veterans who were adept at using the prior electronic portal or other technologies also faced difficulties using the new portal.

They can’t figure out [the new portal], 99% of them that used to use our [old] portal, the electronic secure messaging or emailing between the team, they just can’t use [the new one]. It’s not functioning. (P13, one-year post) Apparently, there’s a link they have to click on to make the new format work for them, and that’s been confusing for them. But I still am having a lot of them tell me, I had somebody recently, who’s very tech savvy, and he couldn’t figure it out, just how to message us. I know they’re still really struggling with that. (P5, 2-months post) And it does seem like the My Vet [my VA Health, new portal], that used to be MyHealtheVet [prior portal], logging on and getting onto that still remains really challenging for a large number of veterans. Like they’re still just unable to do it. So, I do think that, I mean I want to say that there’s positive things, but really, I struggle (P17, one-year post)

Participants recognized difficulties with the new system and expressed empathy for the veterans struggling to access the portal.

I think that a lot of us, individually, that work here, I think we have more compassion for our veterans, because they’re coming in and they can’t even get onto their portal website. (P24, one-year post)

Participants acknowledged that learning a new system may be especially difficult for older veterans or those with less technology experience.

But, you know, veterans, the general population of them are older, in general. So, their technologic skills are limited, and they got used to a system and now they have to change to a new one. (P13, 2-months post) So, for our more elderly veterans who barely turn on the computer, they’re not getting to this new portal. (P8, check in) And you know, I do keep in mind that this is a group of people who aren’t always technologically advanced, so small things, when it’s not normal to them, stymie them.(P13, one-year post)

Concerns were heightened for veterans who were more dependent on the portal as a key element in their care due to specific challenges. One participant pointed out that there may be populations of patients with special circumstances who depend more heavily on the prior portal, MyHealtheVet.

I have veterans from [specific region], that’s the way they communicate. Hearing impaired people can’t hear on the phone, the robocall thing, it doesn’t work, so they use MyHealtheVet. Well, if that goes away, how is that being communicated to the veteran? Ok? (P18, Check-in)

Frustration with inadequate dissemination of information to veterans about EHR transition and use of new portal

Participants were concerned about poor information dissemination to patients about how to access the new portal. During medical encounters, participants often heard from patients about their frustrations accessing the new portal. Participants noted that they could only give their patients a phone number to call for help using the new system but otherwise lacked the knowledge and the time to help them resolve new portal issues. Some clinicians specifically mentioned feeling ill-equipped to handle their patients’ needs for assistance with the new portal. These experiences exacerbated clinician stress during the transition.

Our veterans were using the MyHealtheVet messaging portal, and when our new system went up, it transitioned to My VA Health, but that wasn’t really communicated to the veterans very well. So, what happened was they would go into their MyHealtheVet like they had been doing for all of these years, to go in and request their medications, and when they pulled it up it’d show that they were assigned to a clinician in [a different state], that they have no active medications. Everything was just messed up. And they didn’t know why because there was no alert or notification that things would be changing. (P8, check in) I field all-day frustration from the veterans. And I love my job, I’m not leaving here even as frustrated as I am, because I’m here for them, not to, I’m here to serve the veterans and I have to advocate for them, and I know it will get better, it can’t stay like this. But I constantly field their frustrations.… So, I give them the 1-800 number to a Cerner help desk that helps with that, and I’ve had multiple [instances of] feedback that it didn’t help. (P13, one-year post) And [the patients are] frequently asking me things about their medication [within the portal], when, you know, I can’t help them with that. So, I have to send them back up to the front desk to try to figure out their medications. (P17, one-year post)

Veteran frustration and the burden of additional tasks due to issues with the portal

Clinicians reported that veterans expressed frustration with alternatives to the portal, including long call center wait times. Some veterans chose to walk into the clinic without an appointment rather than wait on the phone. Clinicians noted an increase in walk-ins by frustrated veterans, which placed added workload on clinics that were not staffed to handle the increase in walk-ins.

It’s been kind of clunky also with trying to get that [new portal] transitioned. And then that’s created more walk-ins here, because one, the vets get frustrated with the phone part of it, and then MyHealtheVet (prior portal) not [working], so they end up walking [into the clinic without an appointment]. (P19, check-in) In terms of messages, they can’t necessarily find the clinician they want to message. We had a veteran who came in recently who wanted to talk to their Rheumatologist, and it’s like, yeah, I typed in their name, and nothing came up. So, they have to try calling or coming in. (P20, 2-months post)

In summary, participants described the new patient portal as a source of stress for both themselves and their patients.

In addition to their own direct experience using a new EHR to communicate with their patients, clinicians and staff can be affected by perceptions of their patients’ experiences during an EHR transition [ 19 ]. At this first VA site to transition to the new EHR, clinicians and staff shared their concerns about their patients’ experiences using the portal. They were particularly troubled by unreliability of the secure messaging system and challenges patients faced learning to use the new system without proper instruction. Moreover, clinicians were alarmed to hear about patients having to make in-person visits– especially unplanned (i.e., walk in) ones– due to challenges with the new portal. Each of these issues needs to be addressed to ensure veteran satisfaction. However, the only solution participants could offer to frustrated patients was the telephone number to the help desk, leaving them with no clear knowledge of a solution strategy or a timeline for resolution of the issues.

We propose applying emergency preparedness actions to future EHR rollouts: mitigate, prepare, respond, and recover (Fig.  1 ) [ 13 ]. By applying these actions, patient portal disruptions may be alleviated and patients’ communication with their clinicians and access to care can be maintained. For example, issues stemming from a disruption in the portal may be mitigated by first identifying and understanding which patients typically use the portal and how they use it. Sites can use this information to prepare for the transition by disseminating instructional materials to staff and patients on how to access the new portal, targeting the most common and critical portal uses. Sites can respond to any expected and emerging portal disruptions by increasing access to alternative mechanisms for tasks disrupted by and typically completed within the portal. After the transition, recovery can begin by testing and demonstrating the accuracy and reliability of functions in the new portal. These actions directly address reported clinician concerns and can help maintain patient-clinician communication, and access to care.

The emergency preparedness framework was applied. This framework includes 4 actions: (1) mitigate, (2) prepare, (3) respond, and (4) recover. These actions can be repeated. Recommendations for how each action (1–4) can be applied to a portal transition are included in each blue quadrant of the circle

Sites could mitigate issues by first understanding which patients will be most affected by the transition, such as those who rely heavily on secure messaging. Reliable use of secure messaging within the VA facilitates positive patient-clinician relationships by providing a mechanism for efficient between-visit communication [ 20 , 21 , 22 , 23 ]. During the EHR transition, clinicians and staff became concerned about the well-being of patients from whom they weren’t receiving messages and those who depended on the portal to complete certain tasks. Since secure messaging is often initiated by patients to clinicians [ 23 ], clinicians will likely be unaware that messages are being missed. Understanding how and which patients currently use the portal and anticipating potential portal needs is a first step toward mitigating potential issues.

Despite efforts to inform Veterans of the EHR transition and patient portal [ 24 ] including information sent to a Veteran by email, direct mail, postings on VA websites, and a town hall, our findings agree with those of Fix and colleagues [ 10 ] and suggest that many Veterans were unprepared for the transition. Our findings suggest that end users heard that more is needed to improve the dissemination of knowledge about the transition and how to navigate the new patient portal to both VA employees and the patients they serve.

Preparations for the transition should prioritize providing VA clinicians and staff with updated information and resources on how to access and use the new portal [ 25 ]. VA clinicians deliver quality care to veterans and many VA employees are proud to serve the nation’s veterans and willing to go the extra mile to support their patients’ needs [ 26 ]. In this study, participants expressed feeling unprepared to assist or even respond to their patients’ questions and concerns about using the new portal. This unpreparedness contributed to increased clinician and staff stress, as they felt ill-equipped to help their patients with portal issues. Such experiences can negatively affect the patient-clinician relationship. Preparing clinicians and patients about an upcoming transition, including technical support for clinicians and patients, may help minimize these potential issues [ 10 , 27 ]. Specialized training about an impending transition, along with detailed instructions on how to gain access to the new system, and a dedicated portal helpline may be necessary to help patients better navigate the transition [ 23 , 28 ].

In addition to a dedicated helpline, our recommendations include responding to potential changes in needed veteran services during the transition. In our study, participants observed more veteran walk-ins due to challenges with the patient portal. Health systems need to anticipate and address this demand by expanding access to in-person services and fortifying other communication channels. For example, sites could use nurses to staff a walk-in clinic to handle increases in walk-in traffic and increase call center capacity to handle increases in telephone calls [ 29 ]. Increased use of walk-in clinics have received heightened attention as a promising strategy for meeting healthcare demands during the COVID-19 pandemic [ 30 ] and can potentially be adapted for meeting care-related needs during an EHR transition. These strategies can fill a gap in communication between clinicians and their patients while patients are learning to access and navigate a new electronic portal.

Finally, there is a need for a recovery mechanism to restore confidence in the reliability of the EHR and the well-being of clinicians and staff. Healthcare workers are experiencing unprecedented levels of stress [ 31 ]. A plan must be in place to improve and monitor the accuracy of data migrated, populated, and processed within the new system [ 2 ]. Knowing that portal function is monitored could help ease clinician and staff concerns and mitigate stress related to the transition.

Limitations

This study has several limitations. First, data collection relied on voluntary participation, which may introduce self-selection response bias. Second, this work was completed at one VA medical center that was the first site in the larger enterprise-wide transition, and experiences at other VAs or healthcare systems might differ substantially. Third, we did not interview veterans and relied entirely on secondhand accounts of patient experiences with the patient portal. Future research should include interviews with veterans during the transition and compare veteran and VA employee experiences.

Despite a current delay in the deployment of the new EHR at additional VA medical centers, findings from this study offer timely lessons that can ensure clinicians and staff are equipped to navigate challenges during the transition. The strategies presented in this paper could help maintain patient-clinician communication and improve veteran experience. Guided by the emergency preparedness framework, recommended strategies to address issues presented here include alerting those patients most affected by the EHR transition, being prepared to address patients’ concerns, increasing staffing for the help desk and walk-in care clinics, and monitoring the accuracy and reliability of the portal to provide assurance to healthcare workers that patients’ needs are being met. These strategies can inform change management at other VA medical centers that will soon undergo EHR transition and may have implications for other healthcare systems undergoing patient portal changes. Further work is needed to directly examine the perspectives of veterans using the portals, as well as the perspectives of both staff and patients in the growing number of healthcare systems beyond VA that are preparing for an EHR-to-EHR transition.

Data availability

Deidentified data analyzed for this study are available from the corresponding author on reasonable request.

Abbreviations

Electronic health record

Department of Veterans Affairs

VA Medical Centers

Department of Defense

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Acknowledgments

We acknowledge and thank members of the EMPIRIC Evaluation qualitative and supporting team for their contributions to this work including Ellen Ahlness, PhD, Julian Brunner, PhD, Adena Cohen-Bearak, MPH, M.Ed, Leah Cubanski, BA, Christine Firestone, Bo Kim, PhD, Megan Moldestad, MS, and Rachel Smith. We greatly appreciate the staff at the Mann-Grandstaff VA Medical Center and associated community-based outpatient clinics for generously sharing of their time and experiences participating in this study during this challenging time.

The “EHRM Partnership Integrating Rapid Cycle Evaluation to Improve Cerner Implementation (EMPIRIC)” (PEC 20–168) work was supported by funding from the US Department of Veterans Affairs, Veterans Health Administration, Health Services Research & Development Quality Enhancement Research Initiative (QUERI) (PEC 20–168). The findings and conclusions in this article are those of the authors and do not necessarily reflect the views of the Veterans Health Administration, Veterans Affairs, or any participating health agency or funder.

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Authors and affiliations.

VA Northeast Ohio Healthcare System, 10701 East Blvd., Research Service 151, 44106, Cleveland, OH, USA

Sherry L. Ball

Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA

Bo Kim & Seppo T. Rinne

Department of Psychiatry, Harvard Medical School, Boston, MA, USA

Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA

Sarah L. Cutrona & Brianne K. Molloy-Paolillo

Division of Health Informatics & Implementation Science, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA

Sarah L. Cutrona

Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Puget Sound Health Care System, Seattle, WA, USA

Ellen Ahlness, Megan Moldestad & George Sayre

University of Washington School of Public Health, Seattle, WA, USA

George Sayre

Geisel School of Medicine at Dartmouth, Hannover, NH, USA

Seppo T. Rinne

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Contributions

S.R. designed the larger study. G.S. was the qualitative methodologist who led the qualitative team. S.B., E.A., and M.M. created the interview guides and completed the interviews; Data analysis, data interpretation, and the initial manuscript draft were completed by S.B. and B.K. S.C. and B.M. worked with the qualitative team to finalize the analysis and edit and finalize the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Sherry L. Ball .

Ethics declarations

Ethics approval and consent to participate.

This evaluation was designated as non-research/quality improvement by the VA Bedford Healthcare System Institutional Review Board. All methods were carried out in accordance with local and national VA guidelines and regulations for quality improvement activities. This study included virtual interviews with participants via MS Teams. Employees volunteered to participate in interviews and verbal consent was obtained to record interviews. Study materials, including interview guides with verbal consent procedures, were reviewed and approved by labor unions and determined as non-research by the VA Bedford Healthcare System Institutional Review Board.

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The findings and conclusions in this paper are those of the authors and do not necessarily represent the official position of the Department of Veterans Affairs.

Prior presentations

Ball S, Kim B, Moldestad M, Molloy-Paolillo B, Cubanski L, Cutrona S, Sayre G, and Rinne S. (2022, June). Electronic Health Record Transition: Providers’ Experiences with Frustrated Patients. Poster presentation at the 2022 AcademyHealth Annual Research Meeting. June 2022.

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The authors declare no competing interests.

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Ball, S.L., Kim, B., Cutrona, S.L. et al. Clinician and staff experiences with frustrated patients during an electronic health record transition: a qualitative case study. BMC Health Serv Res 24 , 535 (2024). https://doi.org/10.1186/s12913-024-10974-5

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Received : 29 August 2023

Accepted : 09 April 2024

Published : 26 April 2024

DOI : https://doi.org/10.1186/s12913-024-10974-5

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