A multidisciplinary VA project team contributed to the evaluation. Team members included physicians with expertise in primary care, geriatrics, and dementia; a veteran consultant; GRECC Connect leadership; and researchers with expertise in qualitative methods and project coordination.

REVISIT was designed as a template to be populated with data from the veteran’s electronic health record (EHR). A member of the team with a background in media design drafted template options on Canva (Canva), a free web-based graphic design platform. REVISIT’s design drew upon VA’s Patient Experience Journey Map, a visual representation of commonly experienced moments before, during, and after a veteran’s health care visit [16]. Draft REVISIT templates were presented to the full multidisciplinary team for review, resulting in 3 iterative rounds of feedback and refinement.

The information included in the final iteration of REVISIT focused on aspects of the index visit we sought to confirm and explore, which were separated into three groupings: (1) the referral, including the reason and referring provider; (2) the index visit, including individuals present and main topics discussed; and (3) changes in the veteran’s health and health care resulting from the visit, including changes in diagnoses, medications, and referrals.

The overall structure of the first iteration of REVISIT (Figure 1) contained 3 columns, with each column representing a step in the GRECC Connect visit (before, during, and after the visit). For the first iteration, initial refinements suggested by the team focused on simplifying the template to include only information pertinent to the interview. Team members also felt REVISIT should focus more on the “Post-Visit” section to better aid participants’ recall of what worked well about the visit and what health needs remained unmet.

The second iteration (Figure 2) incorporated the aforementioned feedback for simplification. For example, the “Pre-Visit” section was changed completely to include only GRECC Connect referral information, and the heading for this section was edited to “Referral” to reflect this change. The “GRECC Connect Visit” section still included persons present during the index visit, but the other sections were collapsed into one summary of the visit details. The “Post-Visit” section was expanded to take up more of the page, emphasizing this section as the focus of the interview.

After reviewing the second iteration, the team encouraged further simplification of the template’s design to reflect REVISIT’s primary goal of helping participants recall details about their experience of the telemedicine visit. Team review of the second iteration also focused on possible modifications to the included language. EHRs contain medical jargon that is likely unfamiliar to interview participants. Team members suggested translation of these terms into more lay language for the last iteration, a process that relied heavily on input from the physician team members.

Design considerations for the final REVISIT iteration (Figure 3) included using boxes with rounded edges, as the team felt this connoted friendliness compared to the sharp edges shown in Figure 1. Icons were included alongside text descriptions wherever possible to increase ease of understanding. Arrows showed flow from one section to the next, green “+” symbols signified newly prescribed medications, and red “x” symbols signified deprescribed medications. Calibri font was used in accordance with VA’s graphic design standards.

The colors of each section were specifically chosen based on color-in-context theory [17], which posits color meanings are grounded in learned associations that develop from repeated pairings of colors with particular messages, concepts, or experiences. The color motif was loosely based on the 3 phases of a traffic light—the initial referral to GRECC Connect was yellow (to symbolize a transition) and the postvisit was green (to symbolize moving forward). Blue, as opposed to red, was chosen to represent the index visit because of its generally accepted calming effects [18]. The team felt this was a more suitable color choice, given the potentially sensitive topics that may surface during discussion of the index visit during interviews. The team also opted for colors with lighter versus darker hues, as these were felt to be easier on the eyes.

Language edits were incorporated into the final iteration. Potentially sensitive medical issues such as dementia diagnoses or cognitive decline were instead referred to as “memory changes.” We deemed this step necessary as it was sometimes unclear, based on the medical notes, what was explicitly discussed with the participant versus only documented in the clinic note. The inclusion of more neutral language helped ensure that REVISIT would avoid distressing a participant with potentially new information about their health.

REVISIT was used in the context of a health care evaluation with a sample of 30 rural veterans attending specialty geriatric telemedicine visits at 6 geographically diverse GRECC Connect hub sites. We defined “telemedicine” as medical appointments conducted through one of three modalities: (1) video appointments from a veteran’s home or other location to a remote specialist using VA Video Connect (VVC), (2) video appointments from a VA outpatient clinic near the veteran’s home to a remote specialist using Clinical Video Telehealth (CVT), or (3) telephone. An option to participate as a veteran-caregiver dyad was offered in cases where veteran participants had some degree of cognitive impairment or where caregivers were substantially involved in care. Due to the impact of dementia, some dyads were primarily represented by the caregiver.

Prior to initial contact, 3 team members briefly reviewed each veteran’s EHR to confirm the most recent telemedicine visit date and modality (VVC, CVT, or phone), veteran location, initial reason for referral, the presence of a caregiver, and any cognitive or other health concerns that would preclude study participation (eg, a veteran in hospice or deceased). Veterans were considered eligible for participation if they were 65 years and older of age, resided in a rural area (rural-urban commuting area [RUCA] >1), participated in a telemedicine GRECC Connect appointment between December 2020 and March 2021, and spoke English as their primary language. Verbal permission was obtained from each veteran and caregiver to participate in the evaluation.

Once participants agreed to participate in an interview, a team member performed a detailed chart abstraction of the veteran’s EHR 6 months prior to the index appointment using a structured data abstraction template (Multimedia Appendix 1). This data abstraction template helped team members extract only information relevant to the GRECC Connect visit from the participant’s EHR, which can contain many notes from numerous clinicians. GRECC physicians on the multidisciplinary team helped to develop the data abstraction template and interpret EHR data when questions arose. These data were then used to populate REVISIT to create an individualized visual appointment summary and tailored interview guide for each participant. To protect participants’ health information, each populated REVISIT was saved in a password-protected participant-specific folder on a secure server. On average, team members spent 2 to 4 hours abstracting data and creating the visual summary. Time varied depending on the extensiveness and clarity of the participant’s medical chart.

Four experienced qualitative researchers conducted semistructured qualitative interviews with veterans and their caregivers who agreed to participate in the evaluation. We asked participants about their GRECC Connect telemedicine visit, including support received, what worked and did not work well, preferred modality for medical care, impact of visit, satisfaction, and recommendations. Interviews took place approximately a month after the index visit and were conducted via VVC or by phone depending on participant preference and ability. In total, 16 interviews were conducted via VVC on various devices (eg, smartphone, tablet, and laptop), and 14 were conducted by phone.

REVISIT was shared with participants who were interviewed via VVC using its screen-sharing feature. The use of REVISIT was incorporated into the GRECC Connect interview guide. The interviewer shared REVISIT when beginning to discuss the index visit following initial rapport-building questions. In at least one case, REVISIT was shown earlier in the interview because the participant needed more recall support.

Following the data collection process, team members who conducted interviews debriefed their experience using REVISIT, sharing the benefits and challenges of using the tool. Elements of the debrief were recorded on digital sticky notes, which were then grouped together by theme along the project timeline. Team members’ perspectives were informed by observations of participants when REVISIT was shared onscreen. We reviewed participant interview transcripts to find relevant excerpts to illustrate our observations.

The VA Bedford Healthcare System Institutional Review Board determined this work was undertaken to inform VA operations as part of program evaluation and quality improvement activities and was not human subjects research.

REVISIT is a promising visual tool for enhancing the quality of data collected during interviews with older, rural veterans and caregivers. REVISIT enhanced the interview process by providing a focus and catalyst for discussion and supporting rapport-building with participants. Interviewers felt that the tool supported participants’ recollection of the clinical visit, as many participants noted this while sharing additional details about their experience. Our findings demonstrate that the novel use of visual methodologies during videoconference interviews with older adults is feasible and may be useful in supporting the overall success of qualitative evaluations.

Visual methods, combined with in-depth interviews, have been shown to increase data quality, relevance, and trustworthiness [11,13]. Using REVISIT in our evaluation of GRECC Connect appeared to lead to similar enhancements in data quality by aiding participant recall during interviews, resulting in additional disclosure from participants. This finding is consistent with neuroscience principles that demonstrate how visual stimuli evoke brain regions involved in nonverbal information processing and memory [19].

Our experience is also consistent with other studies that demonstrate visual methods support interviewers in facilitating discussions with participants by prompting further questioning by interviewers, providing direction for discussion, streamlining topic transitions, and promoting increased attention [20-24]. Maintaining participant focus on relevant topics during an interview is essential to generating valid data [25]. Yet, researchers have argued that inhibition, or the ability to direct attention away from irrelevant information, declines with age [5]. Using a simplified visual aid such as REVISIT, which we found to provide a focus for discussion, may be particularly useful when interviewing older adults.

Using REVISIT highlighted, for interviewers, difficulties participants experienced recalling details of their index visit. A real-world implication of this insight is that patients may not remember the health and health care information shared by clinicians to properly care for themselves after the visit. For some evaluation participants, viewing REVISIT was the first time they saw any written information about their visit from a practitioner. There are a number of provider-focused information-giving interventions that have been shown to positively influence patient recall [26,27], including intentional specific structuring of written postdischarge information [28]. At the very least, then, as our experience also suggests, older telemedicine patients may benefit from an after-visit summary outlining pertinent details about their health and health care discussed during the visit.

Consistent with previous studies [23], interviewers felt that using a visual memory aid contributed to rapport-building by providing a shared focus with which to interact and reflect upon. Rapport building is an important dimension of interviewing older adults with communication or cognitive barriers, as these challenges may lead them to view interviewers as threatening and increase feelings of powerlessness or a desire to withdraw from study participation [25,29]. Kirkevold and Bergland [30] suggest allocating more time over the course of a project to establish rapport with older interviewees, which can be challenging for research and evaluation projects with strict time constraints. REVISIT addresses this challenge by providing an accelerated rapport-building option for use directly within participant interviews.

The main challenge of using REVISIT as expressed by participants was the inability of some to see the visual due to its light color and font size. Age-related changes in visual acuity and contrast sensitivity can make it more difficult for older adults to read [5]. Therefore, images should have a high degree of contrast and use a large font. Further, participants in this study noted they or others might benefit from viewing images from a larger screen (eg, a tablet or laptop vs a cell phone). Additionally, although our evaluation of GRECC Connect showed it is possible to use visual tools during video interviews with older adults, it does not address potential barriers to the use of technology among this population; limited knowledge, comfort, or experience with technology, challenges with internet access, and existing cognitive and sensory impairments may hinder participants in studies conducted over videoconferencing platforms [31].

Future users of REVISIT and other similar recall aids should be mindful of how to introduce such tools and integrate them into the interview process. REVISIT may diminish rapport if interviewers share the visual at the wrong time; doing so may inadvertently disrupt the flow of the conversation, distracting participants from the interview as they try to make sense of the visual tool. Using REVISIT also reduces the capacity for nonverbal communication when shared on screen, since this action usually minimizes the window of the participant and researcher across videoconferencing platforms. Additionally, if a participant disagrees with the information presented on the visual, it may create confusion, discomfort, or distrust. Another consideration is the substantial amount of time it takes to prepare the visit summaries and subsequent REVISIT visuals for each interviewee. While the preparation time reduced as the team members gained experience with the methodology, given the time investment needed, this method may not be practical for studies with considerably larger sample sizes.

More research is needed to optimize REVISIT’s usability and understand its acceptability among older adults with cognitive impairments. Future research should also explore the extent to which the visual tool affects recall by systematically comparing appointment recall using REVISIT with interview discussion alone. REVISIT may be useful for understanding the experiences of other patient populations with cognitive impairment (eg, traumatic brain injury and posttraumatic stress disorder) or complex medical care (eg, cancer treatment) and adaptable to in-person use (eg, on an iPad or paper). Further research and evaluation are needed to ensure the efficacy of REVISIT with different populations and settings.

This is a preliminary study. Observations were limited to our sample of 16 veterans and veteran-caregiver dyads, most of whom had some degree of cognitive impairment and were interviewed over VVC, as REVISIT use was only possible through its screen-sharing feature. Further, participants were not systematically asked about their experience of viewing and using REVISIT during the interview. Because of this, we only included patient experiences that directly influenced team members’ own experience with and perceptions of the tool. Additionally, though REVISIT appeared to support recall in this study, it does not guarantee that a participant will truly recall relevant details as opposed to simply agreeing with what they are seeing.

REVISIT is a novel visual tool that aids the recall of health care encounters by tapping into memories through nonverbal ways of thinking. The use of REVISIT, a carefully curated visual representation of one particular health care encounter, helps to address a number of threats to generating rich, detailed interview data that may be more prevalent when interviewing older adults. As health services research seeks to understand more diverse patient experiences within health care, a tool such as REVISIT may aid recall of health care experiences for those groups for whom it may be more challenging to collect accurate, rich qualitative data. Further research is needed to understand its usefulness with different populations and settings.