UMass Chan Medical School Faculty Publications

UMMS Affiliation

Department of Quantitative Health Sciences; Graduate School of Nursing; Department of Medicine, Division of Preventative and Behavioral Medicine

Publication Date


Document Type



Health Information Technology | Health Services Administration | Health Services Research | Primary Care


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.


virtual patients, interdisciplinary health teams, clinical staff engagement, environment design, health promotion, tobacco use cessation, UMCCTS funding

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Copyright © Amanda C Blok, Christine N May, Rajani S Sadasivam, Thomas K Houston. This is an open-access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Medical Education, is properly cited.

DOI of Published Version



JMIR Med Educ. 2017 Feb 15;3(1):e3. doi: 10.2196/mededu.7042. Link to article on publisher's site

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Link to Article in PubMed

Journal/Book/Conference Title

JMIR medical education

PubMed ID