Table 4.

Focus group themes and sample statements describing eHealth technology’s influences for veterans with Post-Traumatic Stress Disorder and comorbid chronic medical conditions.

Themes and subthemes		Sample statements
Interactions with social support
	Receiving support	“The Facebook effect is nice because sometimes you want to connect because you can't pick up the phone and you don’t want to see anybody in person but it’s that little tangible connection you can put something on and you get instant feedback. But I can be negative, too, if you don’t get any feedback.”
		“I use Skype all the time. My mother-in-law lives in (another state) so she sees the daughters on Skype. And I will Skype with someone.”
	Providing mutual support	“...my support system is mostly with (women from a veterans group). I text them because a lot of us don’t like to talk on the phone because sometimes you get too emotional. I just don’t feel like talking to people, but I text a lot of my woman vet and we support each other.”
		“I’m involved with the vet’s center pretty heavily in (the city). I’m there once a week with a group and we all-all of us interact with each other like we’re doing right now, be it cell phone or a text or whatever away from the VA kind of, like what are you doing in terms of this, like in terms of mental health, in terms of losing weight. And I am also involved in a group through another added facet of the VA where we are all PTSD guys and we interact with them. So it’s all about networking with ourselves. Everybody in this room could be networking away from the VA. I don't know how healthy that is but it’s all via communication with our cell phones, primarily.”
	Obtaining support to cope with symptoms or a crisis	“...when I got to my point where I was really at my lowest, you know, I called (my therapist) in the middle of the night and she arranged for someone to come pick me up...if I hadn’t had that, you know, I probably wouldn’t have gone to emergency room or called 9-1-1 or called one of those crisis lines where you have to talk to some stranger.”
		“Because I have one psychologist in (another city) when my PTS was worse, I do not like to see anybody. I just-and then she send me an email, a poem, you know, why I should just don’t give up because I was suicidal. And she sent me that poem I just-you know, and I-just reading that poem kind of saved my life.”
	Deterring social support	“I think sometimes I feel safe on the computer or Facebook but...sometimes it doesn’t really get you out to meet people so that’s why I go on trying to find some social activity to do but I'm doing too much on the computer and I need to push myself out there. Facebook is good but, sometimes, too much is not good.”
Condition management
	Using Web-based tools to manage symptoms	“The (smartphone) is glued to my hand all the time and as soon as they got that PTSD app out...I loaded all my little pictures in there and my phone numbers and you can like send a text when you freak out and it will make a phone call for you.”
		“I...use the PTSD app for my blood pressure because some of the imagery and the progressive relaxation helps me lower my blood pressure.”
	Providing a sense of safety and security	“...when I come to the VA I get really anxious and I see things that trigger me; men that get me angry and people in uniform. I just-I'm always holding my phone because having the Smartphone...Facebook and games, it has helped [my] mental health a lot...”
		“You know, holding a...smartphone or whatever, you know, like I just have a rock in my pocket or something that will calm me down or focusing on something in the room to like kind of calm my anxiety. Those are just some of the things that I use.”
	Signaling reminders	“...now that having a smartphone I have a task list. I put it on task so when I have an appointment or, you know, I put stuff on: tomorrow, don’t forget to go to MyHealth eVet or reorder.”
		“The telephone system for renewing medications works great, you know at least in (town) where I go. And like you were saying, if your prescription is expired, they will automatically send a note to your doctor to request a new one, and that happens quickly. I mean it could take three or four days to get a prescription refilled if your prescription is expired and then getting another refill is probably maybe four days. So it’s really fast. So I don’t have any complaints...”
Access to and communication with providers
	Facilitating accurate reports of pressing or sensitive issues	“...when I was on active duty my psychiatrist and psychologist used email and it was good for them when I would send them an email, I suppose, having like having a difficult time and I could express how I felt at that time; for them to gauge my overall health status and not just what I say when I'm sitting in their chair. And they kept those as records to feed into my medical record so it helped them as much as it helped me.”
		“They could make their visual check because there would be a lot of information on how you appear and they could probably learn more about you if they saw you in your home environment and not how you shower and put on clean clothes to come to the VA.”
	Promoting timely communication between veterans and their providers	“Yeah, I think (using email, secure messaging or texting is) faster for all of us, you know. It kind of frees up their time and they can answer it when they can. And sometimes the (phone) conversation goes a little bit longer because you don’t always think about what you are going to say and it kind of drags on more than what it needs to.”
		“About the email, the one thing that I really like is that the doctor has always got somebody waiting for him, so the nurses are the ones that were logging in to the email and doing the routing of the-and letting him know what’s going on, what the-and I really like that! That’s the sort of addresses the issue that you brought up.”
	Increasing service access for disabled veterans	“When I was on active duty I had the problem like you did. I didn’t want to go out of the house. I couldn’t get out of bed. I couldn’t take a shower. I couldn’t do anything. And they expect you, because I was on medical-waiting for my medical board, and they knew you couldn’t go to work but how can they expect you to get up and drive 45 miles for a doctor’s appointment when you can't even like feed yourself or take a shower?”
		“So when you have all those things, then it’s not making an hour out of your day for an appointment. You have to budget in well, it’s going to take me 15 or 20 minutes in the bathroom to clean myself up; it’s going to take me an hour, hour and a half before I can drive. Now we are talking, you know, two, three hours out of my day. So when I wake up in the morning do I really want to go? Do I really want to deal with it? I don’t want to deal with it. I have other stuff that’s more important. I'm just not going to, whereas, if it was just a Skype phone call then, I would be more likely to participate.”
Information access
	Increasing access to trustworthy health information	“I use the computer a lot and the research-I use the Mayo Clinic and other websites, the VA website. And so when the doctor tells me something then I can go and I can look and find resources or more information.”
		MyHealth eVet...was a good program in order to find information and...be an advocate for my own health. There was a lot of information that I could use...and I could do it from home.”
	Obtaining information from peers	“Because there’s a great blog for PTSD that covers PTSD individual unemployability, so I’m all over that. I don’t know who actually sponsors that blog but, every day there’s probably about 30 or 40 new questions or statements or something so that’s been really helpful.”
		“Sometimes I just Google search a lot. I look for different woman veteran organizations, you know. Just to research and find stuff.
	Opportunities to improve health information access	“I went to the National Council for PTSD and got information. That led me off into a bunch of different directions so when you do your search on the Internet (Web) you can either hit a good spot or a bunch of bad ones...Either way you’re getting a data overload.”
		“I use the Mayo Clinic and other websites, the VA website...The problem that I have is when I have multiple practitioners with different ideas about conditions as far as how to care for them or solve them or even their own interpretation of what the condition is—especially with PTSD.”
Coordination of care
	Improving care coordination across providers and facilities	“I ran into a situation where I was on vacation and I realized that I was running out of the medication and it would take a certain amount of time once I got back to get it refilled. So I got on and I sent my primary doctor an email saying, ‘Hey, I need this renewed’ and I went in to look and see, no it hadn’t. So I had two days later come home, went in to see the pharmacist and she gave me a week’s worth of pills and she immediately put in a message to him, and that day he renewed the prescription. So it was really working well!”
		“So when I was starting to run out of medication, I went in and tried to look for my psychiatrist and I couldn’t. So I sent an email to my primary letting him know what was going on and what had happened. Well, my psychiatrist had forgotten to reissue my medication and they were able to communicate but she and I cannot communicate through the...but I was happy that it was acted on within a day or two. Good communication there...”
	Identifying opportunities for improved care coordination	“I had an experience. My son got out of the Marine Corps about three years ago. He...has PTSD in addition to some other issues. He takes an anti-anxiety medication and so he was up here over Christmas and had forgotten his medication. I took him down...to the VA here. It wasn’t that simple. I mean they could not look up his-even though he’s down in (another) county-he goes to the (VA) clinic down there, they could not look up his stuff in [his hometown VA], and be able to access it up here. So what I had to do is we had to sit there for two and a half hours and get him signed up in (my medical center)...it got him through it, but it was a pain...you know?”