title: Virtual Patient Technology: Engaging Primary Care in Quality Improvement Innovations.
abstract: BACKGROUND
  Engaging health care staff in new quality improvement programs is challenging.
  
  
  OBJECTIVE
  We developed 2 virtual patient (VP) avatars in the context of a clinic-level quality improvement program. We sought to determine differences in preferences for VPs and the perceived influence of interacting with the VP on clinical staff engagement with the quality improvement program.
  
  
  METHODS
  Using a participatory design approach, we developed an older male smoker VP and a younger female smoker VP. The older male smoker was described as a patient with cardiovascular disease and was ethnically ambiguous. The female patient was younger and was worried about the impact of smoking on her pregnancy. Clinical staff were allowed to choose the VP they preferred, and the more they engaged with the VP, the more likely the VP was to quit smoking and become healthier. We deployed the VP within the context of a quality improvement program designed to encourage clinical staff to refer their patients who smoke to a patient-centered Web-assisted tobacco intervention. To evaluate the VPs, we used quantitative analyses using multivariate models of provider and practice characteristics and VP characteristic preference and analyses of a brief survey of positive deviants (clinical staff in practices with high rates of encouraging patients to use the quit smoking innovation).
  
  
  RESULTS
  A total of 146 clinical staff from 76 primary care practices interacted with the VPs. Clinic staff included medical providers (35/146, 24.0%), nurse professionals (19/146, 13.0%), primary care technicians (5/146, 3.4%), managerial staff (67/146, 45.9%), and receptionists (20/146, 13.7%). Medical staff were mostly male, and other roles were mostly female. Medical providers (OR 0.031; CI 0.003-0.281; P=.002) and younger staff (OR 0.411; CI 0.177-0.952; P=.038) were less likely to choose the younger, female VP when controlling for all other characteristics. VP preference did not influence online patient referrals by staff. In high-performing practices that referred 20 or more smokers to the ePortal (13/76), the majority of clinic staff were motivated by or liked the virtual patient (20/26, 77%).
  
  
  CONCLUSIONS
  Medical providers are more likely motivated by VPs that are similar to their patient population, while nurses and other staff may prefer avatars that are more similar to them.
authors.affiliation: Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States.|Graduate School of Nursing, University of Massachusetts Medical School, Worcester, MA, United States.
authors.forename: Amanda C
authors.identifier: http://orcid.org/0000-0002-5329-0393
authors.initials: AC
authors.lastname: Blok
authors.affiliation: Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States.|Preventative and Behavioral Medicine, University of Massachusetts Medical School, Worcester, MA, United States.
authors.forename: Christine N
authors.identifier: http://orcid.org/0000-0002-4367-5310
authors.initials: CN
authors.lastname: May
authors.affiliation: Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States.
authors.forename: Rajani S
authors.identifier: http://orcid.org/0000-0001-8406-6207
authors.initials: RS
authors.lastname: Sadasivam
authors.affiliation: Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States.|Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs Medical Center, Bedford, MA, United States.
authors.forename: Thomas K
authors.identifier: http://orcid.org/0000-0002-2909-4018
authors.initials: TK
authors.lastname: Houston
keywords: clinical staff engagement; environment design; health promotion; interdisciplinary health teams; tobacco use cessation; virtual patients