Health information technology to facilitate communication involving health care providers, caregivers, and pediatric patients: a scoping review

Real-World Implementation of Video Outpatient Consultations at Macro, Meso, and Micro Levels: Mixed-Method Study

Background

There is much interest in virtual consultations using video technology. Randomized controlled trials have shown video consultations to be acceptable, safe, and effective in selected conditions and circumstances. However, this model has rarely been mainstreamed and sustained in real-world settings.

Objective

The study sought to (1) define good practice and inform implementation of video outpatient consultations and (2) generate transferable knowledge about challenges to scaling up and routinizing this service model.

Methods

A multilevel, mixed-method study of Skype video consultations (micro level) was embedded in an organizational case study (meso level), taking account of national context and wider influences (macro level). The study followed the introduction of video outpatient consultations in three clinical services (diabetes, diabetes antenatal, and cancer surgery) in a National Health Service trust (covering three hospitals) in London, United Kingdom. Data sources included 36 national-level stakeholders (exploratory and semistructured interviews), longitudinal organizational ethnography (300 hours of observations; 24 staff interviews), 30 videotaped remote consultations, 17 audiotaped face-to-face consultations, and national and local documents. Qualitative data, analyzed using sociotechnical change theories, addressed staff and patient experience and organizational and system drivers. Quantitative data, analyzed via descriptive statistics, included uptake of video consultations by staff and patients and microcategorization of different kinds of talk (using the Roter interaction analysis system).

Results

When clinical, technical, and practical preconditions were met, video consultations appeared safe and were popular with some patients and staff. Compared with face-to-face consultations for similar conditions, video consultations were very slightly shorter, patients did slightly more talking, and both parties sometimes needed to make explicit things that typically remained implicit in a traditional encounter. Video consultations appeared to work better when the clinician and patient already knew and trusted each other. Some clinicians used Skype adaptively to respond to patient requests for ad hoc encounters in a way that appeared to strengthen supported self-management. The reality of establishing video outpatient services in a busy and financially stretched acute hospital setting proved more complex and time-consuming than originally anticipated. By the end of this study, between 2% and 22% of consultations were being undertaken remotely by participating clinicians. In the remainder, clinicians chose not to participate, or video consultations were considered impractical, technically unachievable, or clinically inadvisable. Technical challenges were typically minor but potentially prohibitive.

Conclusions

Video outpatient consultations appear safe, effective, and convenient for patients in situations where participating clinicians judge them clinically appropriate, but such situations are a fraction of the overall clinic workload. As with other technological innovations, some clinicians will adopt readily, whereas others will need incentives and support. There are complex challenges to embedding video consultation services within routine practice in organizations that are hesitant to change, especially in times of austerity.

The role of digital communication in patient–clinician communication for NHS providers of specialist clinical services for young people [the Long-term conditions Young people Networked Communication (LYNC) study]: a mixed-methods study

Background

Young people (aged 16–24 years) with long-term health conditions tend to disengage from health services, resulting in poor health outcomes. They are prolific users of digital communications. Innovative UK NHS clinicians use digital communication with these young people. The NHS plans to use digital communication with patients more widely.

Objectives

To explore how health-care engagement can be improved using digital clinical communication (DCC); understand effects, impacts, costs and necessary safeguards; and provide critical analysis of its use, monitoring and evaluation.

Design

Observational mixed-methods case studies; systematic scoping literature reviews; assessment of patient-reported outcome measures (PROMs); public and patient involvement; and consensus development through focus groups.

Setting

Twenty NHS specialist clinical teams from across England and Wales, providing care for 13 different long-term physical or mental health conditions.

Participants

One hundred and sixty-five young people aged 16–24 years living with a long-term health condition; 13 parents; 173 clinical team members; and 16 information governance specialists.

Interventions

Clinical teams and young people variously used mobile phone calls, text messages, e-mail and voice over internet protocol.

Main outcome measures

Empirical work – thematic and ethical analysis of qualitative data; annual direct costs; did not attend, accident and emergency attendance and hospital admission rates plus clinic-specific clinical outcomes. Scoping reviews–patient, health professional and service delivery outcomes and technical problems. PROMs: scale validity, relevance and credibility.

Data sources

Observation, interview, structured survey, routinely collected data, focus groups and peer-reviewed publications.

Results

Digital communication enables access for young people to the right clinician when it makes a difference for managing their health condition. This is valued as additional to traditional clinic appointments. This access challenges the nature and boundaries of therapeutic relationships, but can improve them, increase patient empowerment and enhance activation. Risks include increased dependence on clinicians, inadvertent disclosure of confidential information and communication failures, but clinicians and young people mitigate these risks. Workload increases and the main cost is staff time. Clinical teams had not evaluated the impact of their intervention and analysis of routinely collected data did not identify any impact. There are no currently used generic outcome measures, but the Patient Activation Measure and the Physicians’ Humanistic Behaviours Questionnaire are promising. Scoping reviews suggest DCC is acceptable to young people, but with no clear evidence of benefit except for mental health.

Limitations

Qualitative data were mostly from clinician enthusiasts. No interviews were achieved with young people who do not attend clinics. Clinicians struggled to estimate workload. Only eight full sets of routine data were available.

Conclusions

Timely DCC is perceived as making a difference to health care and health outcomes for young people with long-term conditions, but this is not supported by evidence that measures health outcomes. Such communication is challenging and costly to provide, but valued by young people.

Future work

Future development should distinguish digital communication replacing traditional clinic appointments and additional timely communication. Evaluation is needed that uses relevant generic outcomes.

Study registration

Two of the reviews in this study are registered as PROSPERO CRD42016035467 and CRD42016038792.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Web-Based Tools for Text-Based Patient-Provider Communication in Chronic Conditions: Scoping Review

BACKGROUND

Patients with chronic conditions require ongoing care which not only necessitates support from health care providers outside appointments but also self-management. Web-based tools for text-based patient-provider communication, such as secure messaging, allow for sharing of contextual information and personal narrative in a simple accessible medium, empowering patients and enabling their providers to address emerging care needs.

OBJECTIVE

The objectives of this study were to (1) conduct a systematic search of the published literature and the Internet for Web-based tools for text-based communication between patients and providers; (2) map tool characteristics, their intended use, contexts in which they were used, and by whom; (3) describe the nature of their evaluation; and (4) understand the terminology used to describe the tools.

METHODS

We conducted a scoping review using the MEDLINE (Medical Literature Analysis and Retrieval System Online) and EMBASE (Excerpta Medica Database) databases. We summarized information on the characteristics of the tools (structure, functions, and communication paradigm), intended use, context and users, evaluation (study design and outcomes), and terminology. We performed a parallel search of the Internet to compare with tools identified in the published literature.

RESULTS

We identified 54 papers describing 47 unique tools from 13 countries studied in the context of 68 chronic health conditions. The majority of tools (77%, 36/47) had functions in addition to communication (eg, viewable care plan, symptom diary, or tracker). Eight tools (17%, 8/47) were described as allowing patients to communicate with the team or multiple health care providers. Most of the tools were intended to support communication regarding symptom reporting (49%, 23/47), and lifestyle or behavior modification (36%, 17/47). The type of health care providers who used tools to communicate with patients were predominantly allied health professionals of various disciplines (30%, 14/47), nurses (23%, 11/47), and physicians (19%, 9/47), among others. Over half (52%, 25/48) of the tools were evaluated in randomized controlled trials, and 23 tools (48%, 23/48) were evaluated in nonrandomized studies. Terminology of tools varied by intervention type and functionality and did not consistently reflect a theme of communication. The majority of tools found in the Internet search were patient portals from 6 developers; none were found among published articles.

CONCLUSIONS

Web-based tools for text-based patient-provider communication were identified from a wide variety of clinical contexts and with varied functionality. Tools were most prevalent in contexts where intended use was self-management. Few tools for team-based communication were found, but this may become increasingly important as chronic disease care becomes more interdisciplinary.

Relationship Between Physical and Psychological Status of Cancer Patients and Caregivers

The purpose of this study was to describe the relationship between patient physical and emotional status and caregiver mood state for patients with advanced cancer. Data were collected from 299 cancer patients and their caregivers from a cancer center. We used a longitudinal design and collected data through interviews. The relationships between patient and caregiver emotional states over time were moderate and statistically significant at all three points in time (p values = .012-.0001). Patient physical and emotional status predicted caregiver mood state at all points in time (βs = -.22 to -.25) and caregiver mood state at baseline predicted patient emotional status at 3 months (β = -.16, p = .013). Relationships between patient emotional status and caregiver mood state were moderately strong. Addressing the emotional needs of both patients and caregivers has the potential to yield improved emotional outcomes for both over time.

Timely Digital Patient-Clinician Communication in Specialist Clinical Services for Young People: A Mixed-Methods Study (The LYNC Study)

Background

Young people (aged 16-24 years) with long-term health conditions can disengage from health services, resulting in poor health outcomes, but clinicians in the UK National Health Service (NHS) are using digital communication to try to improve engagement. Evidence of effectiveness of this digital communication is equivocal. There are gaps in evidence as to how it might work, its cost, and ethical and safety issues.

Objective

Our objective was to understand how the use of digital communication between young people with long-term conditions and their NHS specialist clinicians changes engagement of the young people with their health care; and to identify costs and necessary safeguards.

Methods

We conducted mixed-methods case studies of 20 NHS specialist clinical teams from across England and Wales and their practice providing care for 13 different long-term physical or mental health conditions. We observed 79 clinical team members and interviewed 165 young people aged 16-24 years with a long-term health condition recruited via case study clinical teams, 173 clinical team members, and 16 information governance specialists from study NHS Trusts. We conducted a thematic analysis of how digital communication works, and analyzed ethics, safety and governance, and annual direct costs.

Results

Young people and their clinical teams variously used mobile phone calls, text messages, email, and voice over Internet protocol. Length of clinician use of digital communication varied from 1 to 13 years in 17 case studies, and was being considered in 3. Digital communication enables timely access for young people to the right clinician at the time when it can make a difference to how they manage their health condition. This is valued as an addition to traditional clinic appointments and can engage those otherwise disengaged, particularly at times of change for young people. It can enhance patient autonomy, empowerment and activation. It challenges the nature and boundaries of therapeutic relationships but can improve trust. The clinical teams studied had not themselves formally evaluated the impact of their intervention. Staff time is the main cost driver, but offsetting savings are likely elsewhere in the health service. Risks include increased dependence on clinicians, inadvertent disclosure of confidential information, and communication failures, which are mostly mitigated by young people and clinicians using common-sense approaches.

Conclusions

As NHS policy prompts more widespread use of digital communication to improve the health care experience, our findings suggest that benefit is most likely, and harms are mitigated, when digital communication is used with patients who already have a relationship of trust with the clinical team, and where there is identifiable need for patients to have flexible access, such as when transitioning between services, treatments, or lived context. Clinical teams need a proactive approach to ethics, governance, and patient safety.

Using eHealth Technologies: Interests, Preferences, and Concerns of Older Adults

BACKGROUND

The Internet and eHealth technologies represent new opportunities for managing health. Age, sex, socioeconomic status, and current technology use are some of the known factors that influence individuals' uptake of eHealth; however, relatively little is known about facilitators and barriers to eHealth uptake specific to older adults, particularly as they relate to their experiences in accessing health care.

OBJECTIVE

The aim of our study was to explore the interests, preferences, and concerns of older adults in using the Internet and eHealth technologies for managing their health in relation to their experiences with the current health care system.

METHODS

Two focus groups (n=15) were conducted with adults aged 50+ years. Pragmatic thematic analysis using an inductive approach was conducted to identify the interests, preferences, and concerns of using the Internet and eHealth technologies.

RESULTS

Five themes emerged that include (1) Difficulty in identifying credible and relevant sources of information on the Web; (2) Ownership, access, and responsibility for medical information; (3) Peer communication and support; (4) Opportunities to enhance health care interactions; and (5) Privacy concerns. These findings support the potential value older adults perceive in eHealth technologies, particularly in their ability to provide access to personal health information and facilitate communication between providers and peers living with similar conditions. However, in order to foster acceptance, these technologies will need to provide personal and general health information that is secure, readily accessible, and easily understood.

CONCLUSIONS

Older adults have diverse needs and preferences that, in part, are driven by their experiences and frustrations with the health care system. Results can help inform the design and implementation of technologies to address gaps in care and access to health information for older adults with chronic conditions who may benefit the most from this approach.

The OCarePlatform: A context-aware system to support independent living

BACKGROUND

Currently, healthcare services, such as institutional care facilities, are burdened with an increasing number of elderly people and individuals with chronic illnesses and a decreasing number of competent caregivers.

OBJECTIVES

To relieve the burden on healthcare services, independent living at home could be facilitated, by offering individuals and their (in)formal caregivers support in their daily care and needs. With the rise of pervasive healthcare, new information technology solutions can assist elderly people ("residents") and their caregivers to allow residents to live independently for as long as possible.

METHODS

To this end, the OCarePlatform system was designed. This semantic, data-driven and cloud-based back-end system facilitates independent living by offering information and knowledge-based services to the resident and his/her (in)formal caregivers. Data and context information are gathered to realize context-aware and personalized services and to support residents in meeting their daily needs. This body of data, originating from heterogeneous data and information sources, is sent to personalized services, where is fused, thus creating an overview of the resident's current situation.

RESULTS

The architecture of the OCarePlatform is proposed, which is based on a service-oriented approach, together with its different components and their interactions. The implementation details are presented, together with a running example. A scalability and performance study of the OCarePlatform was performed. The results indicate that the OCarePlatform is able to support a realistic working environment and respond to a trigger in less than 5 seconds. The system is highly dependent on the allocated memory.

CONCLUSION

The data-driven character of the OCarePlatform facilitates easy plug-in of new functionality, enabling the design of personalized, context-aware services. The OCarePlatform leads to better support for elderly people and individuals with chronic illnesses, who live independently.

BMT Roadmap: A User-Centered Design Health Information Technology Tool to Promote Patient-Centered Care in Pediatric Hematopoietic Cell Transplantation

Health information technology (HIT) has great potential for increasing patient engagement. Pediatric hematopoietic cell transplantation (HCT) is a setting ripe for using HIT but in which little research exists. "BMT Roadmap" is a web-based application that integrates patient-specific information and includes several domains: laboratory results, medications, clinical trial details, photos of the healthcare team, trajectory of transplant process, and discharge checklist. BMT Roadmap was provided to 10 caregivers of patients undergoing first-time HCT. Research assistants performed weekly qualitative interviews throughout the patient's hospitalization and at discharge and day 100 to assess the impact of BMT Roadmap. Rigorous thematic analysis revealed 5 recurrent themes: emotional impact of the HCT process itself; critical importance of communication among patients, caregivers, and healthcare providers; ways in which BMT Roadmap was helpful during inpatient setting; suggestions for improving BMT Roadmap; and other strategies for organization and management of complex healthcare needs that could be incorporated into BMT Roadmap. Caregivers found the tool useful and easy to use, leading them to want even greater access to information. BMT Roadmap was feasible, with no disruption to inpatient care. Although this initial study is limited by the small sample size and single-institution experience, these initial findings are encouraging and support further investigation.

An eHealth information technology platform to help the treatment of mental disorders

For this project, we have used new technologies to create a new channel of communication between doctors and patients in the treatment of mental disorders. We have created a web application using an adaptable design accessible from any mobile device, which allows doctors to adapt their patients' therapy to real-time knowledge of their current condition. In turn, patients can express their mood state with respect to the component elements of their therapy.

An e-health intervention to support the transition of young people with long-term illnesses to adult healthcare services: Design and early use

OBJECTIVE

Co-design information and website to support adolescents and young adults with long-term illnesses in their transition to adult healthcare.

METHODS

A participatory iterative process involving a survey (n=207), twenty-one interviews, six participatory workshops, six video recordings, two advisory groups, and a co-design group to identify needs and preferences for e-health and information provision, was used to develop an appropriate intervention.

RESULTS

Adolescents and young people expressed preferences for information that was trustworthy, empowering, colorful, easily downloaded online and written using non-patronizing language. They desired video testimonials of experiences from young adults who had transitioned to adult healthcare and wanted advice about becoming more independent, managing their condition, preparing for the transition, and information about medications and the differences between child and adult healthcare. They also wanted information about the location and configuration of adult healthcare, key hospital personnel, and frequently asked questions.

CONCLUSION

The participatory iterative process led to the development of an online resource specifically tailored to the adolescents and young people's transition needs and information preferences. Preliminary feedback indicates that it is a valued resource.

PRACTICE IMPLICATIONS

The www.SteppingUP.ie website has the potential to help prepare its target population group for the transition to adult healthcare.

Transition from childhood to adulthood in coeliac disease: the Prague consensus report

The process of transition from childhood to adulthood is characterised by physical, mental and psychosocial development. Data on the transition and transfer of care in adolescents/young adults with coeliac disease (CD) are scarce. In this paper, 17 physicians from 10 countries (Sweden, Italy, the USA, Germany, Norway, the Netherlands, Australia, Britain, Israel and Denmark) and two representatives from patient organisations (Association of European Coeliac Societies and the US Celiac Disease Foundation) examined the literature on transition from childhood to adulthood in CD. Medline (Ovid) and EMBASE were searched between 1900 and September 2015. Evidence in retrieved reports was evaluated using the Grading of Recommendation Assessment, Development and Evaluation method. The current consensus report aims to help healthcare personnel manage CD in the adolescent and young adult and provide optimal care and transition into adult healthcare for patients with this disease. In adolescence, patients with CD should gradually assume exclusive responsibility for their care, although parental support is still important. Dietary adherence and consequences of non-adherence should be discussed during transition. In most adolescents and young adults, routine small intestinal biopsy is not needed to reconfirm a childhood diagnosis of CD based on European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) or North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) criteria, but a biopsy may be considered where paediatric diagnostic criteria have not been fulfilled, such as, in a patient without biopsy at diagnosis, additional serology (endomysium antibody) has not been performed to confirm 10-fold positivity of tissue transglutaminase antibodies or when a no biopsy strategy has been adopted in an asymptomatic child.

Does mobile phone ownership predict better utilization of maternal and newborn health services? a cross-sectional study in Timor-Leste

Background

Increasingly popular mobile health (mHealth) programs have been proposed to promote better utilization of maternal, newborn and child health services. However, women who lack access to a mobile phone are often left out of both mHealth programs and research. In this study, we determine whether household mobile phone ownership is an independent predictor of utilization of maternal and newborn health services in Timor-Leste.

Methods

The study included 581 women aged 15–49 years with a child under the age of two years from the districts of Manufahi and Ainaro in Timor-Leste. Participants were interviewed via a structured survey of knowledge, practices, and coverage of maternal and child health services, with additional questions related to ownership and utilization of mobile phones. Mobile phone ownership was the exposure variable, and the dependent variables included having at least four antenatal care visits, skilled birth attendance, health facility delivery, a postnatal checkup within 24 h, and a neonatal checkup within 24 h for their youngest child. Logistic regression models were applied to assess for associations.

Results

Sixty-seven percent of women reported having at least one mobile phone in the family. Women who had a mobile phone were significantly more likely to be of higher socioeconomic status and to utilize maternal and newborn health services. However, after adjusting socioeconomic factors, household mobile phone ownership was not independently associated with any of the dependent variables.

Conclusion

Evaluations of the effects of mHealth programs on health in a population need to consider the likelihood of socioeconomic differentials indicated by mobile phone ownership.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-0981-1) contains supplementary material, which is available to authorized users.

E-health and health care behaviour of parents of young children: a qualitative study

OBJECTIVE

Internet plays a huge role in providing information about health care problems. However, it is unknown how parents use and perceive the internet as a source of information and how this influences health care utilisation when it comes to common complaints in infants. The objective was to evaluate the perception parents have on the role of internet in providing health care information on common symptoms in infants and its effects on health care utilisation.

DESIGN

A qualitative design was chosen.

SETTING AND SUBJECTS

Parents were recruited from a population-based birth-cohort and selected purposefully.

MAIN OUTCOME MEASURES

Semi-structured interviews were used to receive information of parents' ideas. Thematic coding and constant comparison were used for interview transcript analysis.

RESULTS

Ten parents were interviewed. Parents felt anxious and responsible when their child displayed common symptoms, and appeared to be in need of information. They tried to obtain information from relatives, but more so from the internet, because of its accessibility. Nevertheless, information found on the internet had several limitations, evoked new doubts and insecurity and although parents compared information from multiple sources, only the physician was able to take away the insecurity. The internet did not interfere in the decision to consult the physician.

CONCLUSIONS

Parents need information about their children's symptoms and the internet is a major resource. However, only physicians could take away their symptom-related doubts and insecurities and internet information did not play a role in parental decision making. Information gathered online may complement the information from physicians, rather than replace it. Key points Internet plays an increasing role in providing health care information but it is unknown how this influences health care utilisation. Our study suggests that: Parents need information about their children's symptoms and the internet is a major resource. However, only physicians could take away their symptom-related doubts and insecurities. Internet information did not play a role in parental decision making.

In the Loop: The Organization of Team-Based Communication in a Patient-Centered Clinical Collaboration System

Background

We describe the development and evaluation of a secure Web-based system for the purpose of collaborative care called Loop. Loop assembles the team of care with the patient as an integral member of the team in a secure space.

Objective

The objectives of this paper are to present the iterative design of the separate views for health care providers (HCPs) within each patient’s secure space and examine patients’, caregivers’, and HCPs’ perspectives on this separate view for HCP-only communication.

Methods

The overall research program includes cycles of ethnography, prototyping, usability testing, and pilot testing. This paper describes the usability testing phase that directly informed development. A descriptive qualitative approach was used to analyze participant perspectives that emerged during usability testing.

Results

During usability testing, we sampled 89 participants from three user groups: 23 patients, 19 caregivers, and 47 HCPs. Almost all perspectives from the three user groups supported the need for an HCP-only communication view. In an earlier prototype, the visual presentation caused confusion among HCPs when reading and composing messages about whether a message was visible to the patient. Usability testing guided us to design a more deliberate distinction between posting in the Patient and Team view and the Health Care Provider Only view at the time of composing a message, which once posted is distinguished by an icon.

Conclusions

The team made a decision to incorporate an HCP-only communication view based on findings during earlier phases of work. During usability testing we tested the separate communication views, and all groups supported this partition. We spent considerable effort designing the partition; however, preliminary findings from the next phase of evaluation, pilot testing, show that the Patient and Team communication is predominantly being used. This demonstrates the importance of a subsequent phase of the clinical trial of Loop to validate the concept and design.

Nursing Home Provider Perceptions of Telemedicine for Reducing Potentially Avoidable Hospitalizations

OBJECTIVE

Potentially avoidable hospitalizations (PAHs) of nursing home (NH) residents are common, costly, and can have significant economic consequences. Telemedicine has been shown to reduce emergency department and hospitalization of NH residents, yet adoption has been limited and little is known about provider's perceptions and desired functionality for a telemedicine program. The goal of this study was to survey a nationally representative sample of NH physicians and advanced practice providers to quantify provider perceptions and desired functionality of telemedicine in NHs to reduce PAHs.

DESIGN/SETTING/PARTICIPANTS/MEASUREMENT

We surveyed physicians and advanced practice providers who attended the 2015 AMDA-The Society for Post-Acute and Long-Term Care Medicine Annual Conference about their perceptions of telemedicine and desired attributes of a telemedicine program for managing acute changes of condition associated with PAHs.

RESULTS

We received surveys from 435 of the 947 conference attendees for a 45.9% response rate. Providers indicated strong agreement with the potential for telemedicine to improve timeliness of care and fill existing service gaps, while disagreeing most with the ideas that telemedicine would reduce care effectiveness and jeopardize resident privacy. Responses indicated clear preferences for the technical requirements of such a program, such as high-quality audio and video and inclusion of an electronic stethoscope, but with varying opinions about who should be performing the consults.

CONCLUSION

Among NH providers, there is a high degree of confidence in the potential for a telemedicine solution to PAHs in NHs, as well as concrete views about features of such a solution. Such consensus could be used to drive an approach to telemedicine for PAHs in NHs that retains the theoretical strengths of telemedicine and reflects the needs of facilities, providers, and patients. Further research is needed to objectively study the impact of successful telemedicine implementations on patient, provider, and economic outcomes.

Communication Strategies for Empowering and Protecting Children

Communication with children and adolescents is an area that requires special attention. It is our job as health care professionals to ensure that the information being relayed is provided at a level that can be understood, to ensure patient safety as well as keep a child or adolescent engaged in their own medical care and decision making. This article discusses the importance of communication with children, adolescents, and their caregivers. It focuses on the overall importance of health literacy in communicating health care information to both caregivers and their children. Included are points to consider when communicating at different developmental stages, as well as strategies to help establish rapport. Lastly, the importance of technology and how it can help facilitate communication with this population is introduced.

Virtual online consultations: advantages and limitations (VOCAL) study

INTRODUCTION

Remote video consultations between clinician and patient are technically possible and increasingly acceptable. They are being introduced in some settings alongside (and occasionally replacing) face-to-face or telephone consultations.

METHODS

To explore the advantages and limitations of video consultations, we will conduct in-depth qualitative studies of real consultations (microlevel) embedded in an organisational case study (mesolevel), taking account of national context (macrolevel). The study is based in 2 contrasting clinical settings (diabetes and cancer) in a National Health Service (NHS) acute trust in London, UK. Main data sources are: microlevel--audio, video and screen capture to produce rich multimodal data on 45 remote consultations; mesolevel--interviews, ethnographic observations and analysis of documents within the trust; macrolevel--key informant interviews of national-level stakeholders and document analysis. Data will be analysed and synthesised using a sociotechnical framework developed from structuration theory.

ETHICS APPROVAL

City Road and Hampstead NHS Research Ethics Committee, 9 December 2014, reference 14/LO/1883.

PLANNED OUTPUTS

We plan outputs for 5 main audiences: (1) academics: research publications and conference presentations; (2) service providers: standard operating procedures, provisional operational guidance and key safety issues; (3) professional bodies and defence societies: summary of relevant findings to inform guidance to members; (4) policymakers: summary of key findings; (5) patients and carers: 'what to expect in your virtual consultation'.

DISCUSSION

The research literature on video consultations is sparse. Such consultations offer potential advantages to patients (who are spared the cost and inconvenience of travel) and the healthcare system (eg, they may be more cost-effective), but fears have been expressed that they may be clinically risky and/or less acceptable to patients or staff, and they bring significant technical, logistical and regulatory challenges. We anticipate that this study will contribute to a balanced assessment of when, how and in what circumstances this model might be introduced.

Identifying unmet informational needs in the inpatient setting to increase patient and caregiver engagement in the context of pediatric hematopoietic stem cell transplantation

BACKGROUND

Patient-centered care has been shown to improve patient outcomes, satisfaction, and engagement. However, there is a paucity of research on patient-centered care in the inpatient setting, including an understanding of unmet informational needs that may be limiting patient engagement. Pediatric hematopoietic stem cell transplantation (HSCT) represents an ideal patient population for elucidating unmet informational needs, due to the procedure's complexity and its requirement for caregiver involvement.

METHODS

We conducted field observations and semi-structured interviews of pediatric HSCT caregivers and patients to identify informational challenges in the inpatient hospital setting. Data were analyzed using a thematic grounded theory approach.

RESULTS

Three stages of the caregiving experience that could potentially be supported by a health information technology system, with the goal of enhancing patient/caregiver engagement, were identified: (1) navigating the health system and learning to communicate effectively with the healthcare team, (2) managing daily challenges of caregiving, and (3) transitioning from inpatient care to long-term outpatient management.

DISCUSSION

We provide four practical recommendations to meet the informational needs of pediatric HSCT patients and caregivers: (1) provide patients/caregivers with real-time access to electronic health record data, (2) provide information about the clinical trials in which the patient is enrolled, (3) provide information about the patient's care team, and (4) properly prepare patients and caregivers for hospital discharge.

CONCLUSION

Pediatric HSCT caregivers and patients have multiple informational needs that could be met with a health information technology system that integrates data from several sources, including electronic health records. Meeting these needs could reduce patients' and caregivers' anxiety surrounding the care process; reduce information asymmetry between caregivers/patients and providers; empower patients/caregivers to participate in the care process; and, ultimately, increase patient/caregiver engagement in the care process.

Quality of care in rural youth with type 1 diabetes: a cross-sectional pilot assessment

BACKGROUND

Type 1 diabetes mellitus (T1DM) presents a significant health burden for patients and families. The quality of care (QOC) among those living in rural communities is thought to be subpar compared with those in urban communities; however, little data exist to reflect this, especially in pediatric diabetes.

OBJECTIVE

The purpose of this pilot study was to investigate diabetes QOC among families living in rural versus urban areas. 6 QOC markers were used to compare youth with T1DM: appointment adherence, patient-provider communication, diabetes education during clinic visit, congruency with diabetes standards of care, diabetes self-management behaviors, and diabetes-related hospitalizations.

RESEARCH DESIGN AND METHODS

Participants were rural or urban adult caregivers of youth ages 2-18 with ≥10-month history of T1DM receiving treatment at Seattle Children's Hospital, USA. Participants were from rural areas of central Washington, or urban areas of western Washington. Caregivers completed a 26-item survey pertaining to the 6 QOC markers. The 6 QOC markers were compared across 61 participants (34 rural, 27 urban), to determine how diabetes care quality and experiences differed. Data were collected over 12 months. Groups were compared using t-tests and χ² tests, as appropriate.

RESULTS

Compared with urban families, rural families reported significantly lower income and a 4-fold greater usage of public insurance. Among the QOC measures, rural participants were significantly worse off in the appointment adherence, patient-provider communication, and hospitalizations categories. Congruence with diabetes standards of care (foot care only) was also significantly poorer in rural participants.

CONCLUSIONS

The burden of travel in conjunction with the lack of resources in this rural population of families with T1DM youth is cause for concern and warrants further research.

A Novel Health Information Technology Communication System to Increase Caregiver Activation in the Context of Hospital-Based Pediatric Hematopoietic Cell Transplantation: A Pilot Study

BACKGROUND

Pediatric hematopoietic cell transplantation (HCT), commonly referred to as blood and marrow transplantation (BMT), is an intense treatment modality that requires the involvement of engaged caregivers during the patient's (child's) prolonged hospitalization. The ubiquity of electronic health records (EHRs) and a trend toward patient-centered care could allow a novel health information technology (IT) system to increase parental engagement. The paucity of research on acute care, hospital-based (inpatient) health IT applications for patients or caregivers provides an opportunity for testing the feasibility of such applications. The pediatric BMT population represents an ideal patient group to conduct an evaluation due to the lengthy inpatient stays and a heightened need for patient activation.

OBJECTIVE

The primary objective of this study is to assess the feasibility of implementing the BMT Roadmap in caregivers as an intervention during their child's inpatient hospitalization. The BMT Roadmap is an inpatient portal prototype optimized for tablet with a user-centered design. It integrates patient-specific laboratory and medication data from the EHR in real-time and provides support in terms of discharge goals, home care education, and other components. Feasibility will be proven if (1) the BMT Roadmap functions and can be managed by the study team without unexpected effort, (2) the system is accessed by users at a defined minimum threshold, and (3) the qualitative and quantitative research conducted provides quality data that address the perceived usefulness of the BMT Roadmap and could inform a study in a larger sample size.

METHODS

This will be a single-arm, nonrandomized feasibility study. We aim to enroll 10 adult caregivers (age ≥ 18 years) of pediatric patients (aged 0-25 years) undergoing autologous (self-donor) or allogeneic (alternative donor) BMT. Assenting minors (aged 10-18) will also be invited to participate. Recruitment of study participants will take place in the outpatient pediatric BMT clinic. After signing an informed consent, the research study team will provide participants with the BMT Roadmap, available on an Apple iPad, which will used throughout the inpatient hospitalization. To measure the study outcomes, approximately 6-8 semistructured qualitative interviews will be conducted periodically from pre-BMT to 100 days post-BMT and an additional 15-20 semistructured interviews will be conducted among BMT health care providers to assess perceived usefulness and usability of the system, as well as any associated workflow impacts. Quantitative survey instruments will only be administered to adult participants (age ≥ 18 years).

RESULTS

Recruitment will begin in September 2015, and preliminary findings are expected in 2016.

CONCLUSIONS

This protocol offers a framework for the design and analysis of a personalized health IT system that has the potential to increase patient and caregiver engagement in acute care, hospital-based contexts.

Feasibility of Two Educational Methods for Teaching New Mothers: A Pilot Study

BACKGROUND

Printed health educational materials are commonly issued to prepare patients for hospital discharge. Teaching methods that engage multiple senses have been shown to positively affect learning outcomes, suggesting that paper materials may not be the most effective approach when educating new mothers. In addition, many written patient educational materials do not meet national health literacy guidelines. Videos that stimulate visual and auditory senses provide an alternative, potentially more effective, strategy for delivering health information. The acceptability of these methods, as perceived by nurses executing patient education initiatives, is important for determining the most appropriate strategy.

OBJECTIVE

The purpose of this study was to determine the feasibility of 2 educational methods for teaching new mothers how to care for themselves and their infants after hospital discharge. Feasibility was measured by adequate enrollment, acceptability of the intervention to patients and nurses, and initial efficacy.

METHODS

New mothers (n=98) on a Mother-Baby Unit received health information focused on self-care and infant care delivered as either simple printed materials or YouTube videos on an iPad. Mothers completed a pretest, post-test, and an acceptability survey. Following completion of the initiative, nurses who participated in delivering the health education using one of these 2 methods were asked to complete a survey to determine their satisfaction with and confidence in using the materials.

RESULTS

Mothers, on average, were 26 years old; 72% had a high school education; and 41% were African American. The improvement in knowledge scores was significantly higher for the iPad group (8.6% vs 4.4%, P=.02) compared to the pamphlet group. Group (B=4.81, P=.36) and time (B=6.12, P<.001) significantly affected scores, while no significant interaction effect was observed (B=5.69, P=.09). There were no significant differences in responses between the groups (all P values >.05). The nurses had a mean age of 44.3 years (SD 13.9) and had, on average, 16.6 years of experience (SD 13.8). The nurses felt confident and satisfied administering both educational modalities.

CONCLUSIONS

The pamphlet and iPad were identified as feasible and acceptable modalities for educating new mothers about self-care and infant care, though the iPad was more effective in improving knowledge. Understanding the acceptability of different teaching methods to patient educators is important for successful delivery of informational materials at discharge.

Parents' experiences, needs, and preferences in pediatric diabetes care: Suggestions for improvement of care and the possible role of the Internet. A qualitative study

PURPOSE

To investigate the needs and preferences of parents of children with type 1 diabetes (T1D) concerning pediatric diabetes care and use of Internet in care.

DESIGN AND METHODS

Parents of 34 children, aged 2-12, with T1D participated in seven focus group interviews.

RESULTS

Analysis revealed provision of tailored care, disease information, peer support, and accessibility of healthcare professionals as major needs in parents. Internet could be used to satisfy these needs.

PRACTICAL IMPLICATIONS

According to parents, diabetes teams should focus on the impact of the disease, parents' experience, and the child's development, and provide online professional and peer support.

Use of mobile devices and the internet for multimedia informed consent delivery and data entry in a pediatric asthma trial: Study design and rationale

INTRODUCTION

Phase III/IV clinical trials are expensive and time consuming and often suffer from poor enrollment and retention rates. Pediatric trials are particularly difficult because scheduling around the parent, participant and potentially other sibling schedules can be burdensome. We are evaluating using the internet and mobile devices to conduct the consent process and study visits in a streamlined pediatric asthma trial. Our hypothesis is that these study processes will be non-inferior and will be less expensive compared to a traditional pediatric asthma trial.

MATERIALS/METHODS

Parents and participants, aged 12 through 17 years, complete the informed consent process by viewing a multi-media website containing a consent video and study material in the streamlined trial. Participants are provided an iPad with WiFi and EasyOne spirometer for use during FaceTime visits and online twice daily symptom reporting during an 8-week run-in followed by a 12-week study period. Outcomes are compared with participants completing a similarly designed traditional trial comparing the same treatments within the same pediatric health-system. After 8 weeks of open-label Advair 250/50 twice daily, participants in both trial types are randomized to Advair 250/50, Flovent 250, or Advair 100/50 given 1 inhalation twice daily. Study staff track time spent to determine study costs.

RESULTS

Participants have been enrolled in the streamlined and traditional trials and recruitment is ongoing.

CONCLUSIONS

This project will provide important information on both clinical and economic outcomes for a novel method of conducting clinical trials. The results will be broadly applicable to trials of other diseases.

Improving health outcomes for young people with long term conditions: The role of digital communication in current and future patient-clinician communication for NHS providers of specialist clinical services for young people - LYNC study protocol

BACKGROUND

Young people living with long term conditions are vulnerable to health service disengagement. This endangers their long term health. Studies report requests for digital forms of communication - email, text, social media - with their health care team. Digital clinical communication is troublesome for the UK NHS.

AIM

In this article we aim to present the research protocol for evaluating the impacts and outcomes of digital clinical communications for young people living with long term conditions and provide critical analysis of their use, monitoring and evaluation by NHS providers (LYNC study: Long term conditions, Young people, Networked Communications).

METHODS

The research involves: (a) patient and public involvement activities with 16-24 year olds with and without long term health conditions; (b) six literature reviews; (c) case studies - the main empirical part of the study - and (d) synthesis and a consensus meeting. Case studies use a mixed methods design. Interviews and non-participant observation of practitioners and patients communicating in up to 20 specialist clinical settings will be combined with data, aggregated at the case level (non-identifiable patient data) on a range of clinical outcomes meaningful within the case and across cases. We will describe the use of digital clinical communication from the perspective of patients, clinical staff, support staff and managers, interviewing up to 15 young people and 15 staff per case study. Outcome data includes emergency admissions, A&E attendance and DNA (did not attend) rates. Case studies will be analysed to understand impacts of digital clinical communication on patient health outcomes, health care costs and consumption, ethics and patient safety.

A scoping review of scoping reviews: advancing the approach and enhancing the consistency

BACKGROUND

The scoping review has become an increasingly popular approach for synthesizing research evidence. It is a relatively new approach for which a universal study definition or definitive procedure has not been established. The purpose of this scoping review was to provide an overview of scoping reviews in the literature.

METHODS

A scoping review was conducted using the Arksey and O'Malley framework. A search was conducted in four bibliographic databases and the gray literature to identify scoping review studies. Review selection and characterization were performed by two independent reviewers using pretested forms.

RESULTS

The search identified 344 scoping reviews published from 1999 to October 2012. The reviews varied in terms of purpose, methodology, and detail of reporting. Nearly three-quarter of reviews (74.1%) addressed a health topic. Study completion times varied from 2 weeks to 20 months, and 51% utilized a published methodological framework. Quality assessment of included studies was infrequently performed (22.38%).

CONCLUSIONS

Scoping reviews are a relatively new but increasingly common approach for mapping broad topics. Because of variability in their conduct, there is a need for their methodological standardization to ensure the utility and strength of evidence.

Response to a mobile health decision-support system for screening and management of tobacco use

PURPOSE/OBJECTIVES

To describe the predictors of nurse actions in response to a mobile health decision-support system (mHealth DSS) for guideline-based screening and management of tobacco use.

DESIGN

Observational design focused on an experimental arm of a randomized, controlled trial.

SETTING

Acute and ambulatory care settings in the New York City metropolitan area.

SAMPLE

14,115 patient encounters in which 185 RNs enrolled in advanced practice nurse (APN) training were prompted by an mHealth DSS to screen for tobacco use and select guideline-based treatment recommendations.

METHODS

Data were entered and stored during nurse documentation in the mHealth DSS and subsequently stored in the study database where they were retrieved for analysis using descriptive statistics and logistic regressions.

MAIN RESEARCH VARIABLES

Predictor variables included patient gender, patient race or ethnicity, patient payer source, APN specialty, and predominant payer source in clinical site. Dependent variables included the number of patient encounters in which the nurse screened for tobacco use, provided smoking cessation teaching and counseling, or referred patients for smoking cessation for patients who indicated a willingness to quit.

FINDINGS

Screening was more likely to occur in encounters where patients were female, African American, and received care from a nurse in the adult nurse practitioner specialty or in a clinical site in which the predominant payer source was Medicare, Medicaid, or State Children's Health Insurance Program. In encounters where the patient payer source was other, nurses were less likely to provide tobacco cessation teaching and counseling.

CONCLUSIONS

mHealth DSS has the potential to affect nurse provision of guideline-based care. However, patient, nurse, and setting factors influence nurse actions in response to an mHealth DSS for tobacco cessation.

IMPLICATIONS FOR NURSING

The combination of a reminder to screen and integration of guideline-based recommendations into the mHealth DSS may reduce racial or ethnic disparities to screening, as well as clinician barriers related to time, training, and familiarity with resources.

[Preferences in the format of questionnaires and use of the Internet by schoolchildren]

OBJECTIVES

To describe the preferences to complete questionnaires via the internet by schoolchildren, as well as to analyze the attitude towards the use of internet to communicate with health professionals.

METHODS

Cross-sectional study of a school population in Palafolls (Barcelona, n=923) was conducted in October and November 2013. Participants completed both internet and paper versions on a single school day, in random order, and with at least an interval of 2 hours. Preferences to answer internet vs paper version were recorded, along with the willingness to share information with health professionals. Percentages of use preferences and attitudes were estimated, and logistic regression models were fitted to analyze the association with the preferences and willingness to share information with health professionals.

RESULTS

Participation rates were 77% (n=715), of whom 42.4% (38.7 to 46.0) preferred the internet version, and 20.6% (17.6 to 23.6) the paper version. Older children (odds ratio [OR]=0.89, 0.84 to 0.95 for age), and those from families with secondary school (OR=0.63, 0.43 to 0.93), and university degree (OR=0.61, 0.38 to 0.97) were less likely to prefer the internet version, while boys (OR=1.55, 1.10 to 2.16) and those children reporting sedentary habits (OR=1.78, 1.06 to 3.0) were more likely to prefer the internet version. Those scoring higher quality of life (OR=1.03, 1.01-1.05) and not reporting sedentary habits (OR=0.33, 0.15 to 0.73) were factors associated with a positive attitude to share information with health professionals.

CONCLUSIONS

Younger children prefer to use the internet. Although Internet use is very widespread, it is less used to communicate with health professionals.

Improving the care of children with advanced cancer by using an electronic patient-reported feedback intervention: results from the PediQUEST randomized controlled trial

PURPOSE

This study aimed to determine whether feeding back patient-reported outcomes (PROs) to providers and families of children with advanced cancer improves symptom distress and health-related quality of life (HRQoL).

PATIENTS AND METHODS

This study was a parallel, multicentered pilot randomized controlled trial. At most once per week, children age ≥ 2 years old with advanced cancer or their parent completed the computer-based Pediatric Quality of Life and Evaluation of Symptoms Technology (PediQUEST) survey consisting of age- and respondent-adapted versions of the Memorial Symptom Assessment Scale (MSAS), Pediatric Quality of Life Inventory 4.0 Generic Core Scales (PedsQL4.0), and an overall Sickness question. In the intervention group (n = 51), oncologists and families received printed reports summarizing PROs; e-mails were sent to oncologists and subspecialists when predetermined scores were exceeded. No feedback was provided in the control group (n = 53). Primary outcomes included linear trends of MSAS, PedsQL4.0 total and subscale scores, and Sickness scores during 20 weeks of follow-up, along with child, parent, and provider satisfaction with PediQUEST feedback.

RESULTS

Feedback did not significantly affect average MSAS, PedsQL4.0, or Sickness score trends. Post hoc subgroup analyses among children age ≥ 8 years who survived 20 weeks showed that feedback improved PedsQL4.0 emotional (+8.1; 95% CI, 1.8 to 14.4) and Sickness (-8.2; 95% CI, -14.2 to -2.2) scores. PediQUEST reports were valued by children, parents, and providers and contributed at least sometimes to physician initiation of a psychosocial consult (56%).

CONCLUSION

Although routine feedback of PROs did not significantly affect the child's symptoms or HRQoL, changes were in expected directions and improvements observed in emotional HRQoL through exploratory analyses were encouraging. Importantly, children, parents, and providers value PRO feedback.

A systematic review of interactive multimedia interventions to promote children's communication with health professionals: implications for communicating with overweight children

BACKGROUND

Interactive multimedia is an emerging technology that is being used to facilitate interactions between patients and health professionals. The purpose of this review was to identify and evaluate the impact of multimedia interventions (MIs), delivered in the context of paediatric healthcare, in order to inform the development of a MI to promote the communication of dietetic messages with overweight preadolescent children. Of particular interest were the effects of these MIs on child engagement and participation in treatment, and the subsequent effect on health-related treatment outcomes.

METHODS

An extensive search of 12 bibliographic databases was conducted in April 2012. Studies were included if: one or more child-participant was 7 to 11-years-of-age; a MI was used to improve health-related behaviour; child-participants were diagnosed with a health condition and were receiving treatment for that condition at the time of the study. Data describing study characteristics and intervention effects on communication, satisfaction, knowledge acquisition, changes in self-efficacy, healthcare utilisation, and health outcomes were extracted and summarised using qualitative and quantitative methods.

RESULTS

A total of 14 controlled trials, published between 1997 and 2006 met the selection criteria. Several MIs had the capacity to facilitate engagement between the child and a clinician, but only one sought to utilise the MI to improve communication between the child and health professional. In spite of concerns over the quality of some studies and small study populations, MIs were found useful in educating children about their health, and they demonstrated potential to improve children's health-related self-efficacy, which could make them more able partners in face-to-face communications with health professionals.

CONCLUSIONS

The findings of this review suggest that MIs have the capacity to support preadolescent child-clinician communication, but further research in this field is needed. Particular attention should be given to designing appropriate MIs that are clinically relevant.

Internet and mobile technology use among urban African American parents: survey study of a clinical population

BACKGROUND

There is considerable potential for mobile technologies to empower pediatric patients and families by improving their communication with health professionals. National surveys suggest minority parents frequently communicate via mobile technology, but it is uncertain how amenable they are to receiving health care information in this format. Although the low cost and far reach characteristics of mobile health (mHealth) technology makes it advantageous for communication with minority parents, data on acceptance are needed.

OBJECTIVE

The objective of the study was to determine utilization of mobile and Internet technology by African American parents in an urban, underserved population, and to assess their interest in receiving health information via text messaging or other technologies (eg, social media and the Internet).

METHODS

A survey was administered to parents of children aged 1-12 years covered by public insurance receiving care at 3 pediatric primary care centers in Washington, DC.

RESULTS

The African American sample (N=302) was composed of primarily single (75.8%, 229/302) mothers. Almost half had more than a high school education (47.7%, 144/302) and incomes above US $25,000 per year (43.0%, 130/302). Most (97.0%, 293/302) reported owning a cell phone, of which 91.1% (275/302) used it to text and 78.5% (237/302) used it to access the Internet. Most had service plans with unlimited text and data, but 26.5% (80/302) experienced service interruptions in the previous year. Home Internet access was more prevalent among those with higher income (86.2%, 112/130), but it was still relatively pervasive among lower income families (66.9%, 83/124). In adjusted logistic regression models, African American mothers with income greater than US $25,000 annually were 4 times as likely to own a tablet computer than their lower income counterparts. Of the participants, 80.8% (244/302) used social networking, primarily Facebook, and 74.2% (224/302) were interested in joining a social networking group about a health topic concerning their child. Although relatively few African American mothers (17.9%, 54/302) shared health information via texting, there was strong interest in receiving health information via mobile phones (87.4%, 264/302). There was no significant difference in Internet/mobile device use or interest in using these outlets to send/receive information about their children's health between parents of healthy children and parents of children with chronic health conditions.

CONCLUSIONS

Urban African American parents are active users of the Internet and mobile technology for social interactions, but they are less likely to use it for accessing or communicating health information. However, most parents expressed an interest in receiving health information or utilizing social networking to learn more about health topics. Mobile technology and social networks may be an underutilized method of providing health information to underserved minority populations.

Effects of and satisfaction with short message service reminders for patient medication adherence: a randomized controlled study

BACKGROUND

Medication adherence is critical for patient treatment. This study involved evaluating how implementing Short Message Service (SMS) reminders affected patient medication adherence and related factors.

METHODS

We used a structured questionnaire to survey outpatients at three medical centers. Patients aged 20 years and older who were prescribed more than 7 days of a prescription medication were randomized into SMS intervention or control groups. The intervention group received daily messages reminding them of aspects regarding taking their medication; the control group received no messages. A phone follow-up was performed to assess outcomes after 8 days. Data were collected from 763 participants in the intervention group and 435 participants in the control group.

RESULTS

After participants in the intervention group received SMS reminders to take medication or those in the control group received no messages, incidences of delayed doses were decreased by 46.4 and 78.8% for those in the control and intervention groups, respectively. The rate of missed doses was decreased by 90.1% for participants in the intervention group and 61.1% for those in the control group. We applied logistic regression analysis and determined that participants in the intervention group had a 3.2-fold higher probability of having a decrease in delayed doses compared with participants in the control group. Participants in the intervention group also showed a 2.2-fold higher probability of having a decrease in missed doses compared with participants in the control group.

CONCLUSIONS

Use of SMS significantly affected the rates of taking medicine on schedule. Therefore, daily SMS could be useful for reminding patients to take their medicine on schedule.

Communicating during care transitions for older hip fracture patients: family caregiver and health care provider's perspectives

INTRODUCTION

Older hip fracture patients frequently require care across a variety of settings, from multiple individuals, including their family caregivers. We explored issues related to information sharing during transitional care for older hip fracture patients through the perspectives of both health care providers and family caregivers.

METHODS

Thirty-five semi-structured interviews were conducted with family caregivers (n = 9) and health care providers (n = 26) of six hip fracture patients to gather perspectives on information sharing at each care transition, beginning with post-surgical discharge from acute care. Data were analysed using conventional qualitative content analysis methods using NVivo8 software.

RESULTS

Both family caregivers and health care providers recognise that family caregivers' involvement has important benefits for patients, but this involvement is frequently limited by poor information sharing. Barriers include limited staff time, patient privacy regulations and lack of a clear structure to guide information sharing. Receiving, not offering, information was the focus of information sharing by both family caregivers and health care providers.

CONCLUSIONS

Specific barriers that lead to poor information sharing between family caregivers and health care providers have been identified in this study. Possible interventions to improve information sharing include encouraging communication with family caregivers as standard care practice, educational strategies and more effective use of health information systems and technologies.

Bridging organizational divides in health care: an ecological view of health information exchange

BACKGROUND

The fragmented nature of health care delivery in the United States leads to fragmented health information and impedes patient care continuity and safety. Technologies to support interorganizational health information exchange (HIE) are becoming more available. Understanding how HIE technology changes health care delivery and affects people and organizations is crucial to long-term successful implementation.

OBJECTIVE

Our study investigated the impacts of HIE technology on organizations, health care providers, and patients through a new, context-aware perspective, the Regional Health Information Ecology.

METHODS

We conducted more than 180 hours of direct observation, informal interviews during observation, and 9 formal semi-structured interviews. Data collection focused on workflow and information flow among health care team members and patients and on health care provider use of HIE technology.

RESULTS

We structured the data analysis around five primary information ecology components: system, locality, diversity, keystone species, and coevolution. Our study identified three main roles, or keystone species, involved in HIE: information consumers, information exchange facilitators, and information repositories. The HIE technology impacted patient care by allowing providers direct access to health information, reducing time to obtain health information, and increasing provider awareness of patient interactions with the health care system. Developing the infrastructure needed to support HIE technology also improved connections among information technology support groups at different health care organizations. Despite the potential of this type of technology to improve continuity of patient care, HIE technology adoption by health care providers was limited.

CONCLUSIONS

To successfully build a HIE network, organizations had to shift perspectives from an ownership view of health data to a continuity of care perspective. To successfully integrate external health information into clinical work practices, health care providers had to move toward understanding potential contributions of external health information. Our study provides a foundation for future context-aware development and implementation of HIE technology. Integrating concepts from the Regional Health Information Ecology into design and implementation may lead to wider diffusion and adoption of HIE technology into clinical work.

Factors associated with adoption of the electronic health record system among primary care physicians

Background

A territory-wide Internet-based electronic patient record allows better patient care in different sectors. The engagement of private physicians is one of the major facilitators for implementation, but there is limited information about the current adoption level of electronic medical record (eMR) among private primary care physicians.

Objective

This survey measured the adoption level, enabling factors, and hindering factors of eMR, among private physicians in Hong Kong. It also evaluated the key functions and the popularity of electronic systems and vendors used by these private practitioners.

Methods

A central registry consisting of 4324 private practitioners was set up. Invitations for self-administered surveys and the completed questionnaires were sent and returned via fax, email, postal mail, and on-site clinic visits. Current users and non-users of eMR system were compared according to their demographic and practice characteristics. Student’s t tests and chi-square tests were used for continuous and categorical variables, respectively.

Results

A total of 524 completed surveys (response rate 524/4405 11.90%) were collected. The proportion of using eMR in private clinics was 79.6% (417/524). When compared with non-users, the eMR users were younger (users: 48.4 years SD 10.6 years vs non-users: 61.7 years SD 10.2 years, P<.001); more were female physicians (users: 80/417, 19.2% vs non-users: 14/107, 13.1%, P=.013); possessed less clinical experience (with more than20 years of practice: users: 261/417, 62.6% vs non-user: 93/107, 86.9%, P<.001); fewer worked under a Health Maintenance Organization (users: 347/417, 83.2% vs non-users: 97/107, 90.7%, P<.001) and more worked with practice partners (users: 126/417, 30.2% vs non-users: 4/107, 3.7%, P<.001). Efficiency (379/417, 90.9%) and reduction of medical errors (229/417, 54.9%) were the major enabling factors, while patient-unfriendliness (58/107, 54.2%) and limited consultation time (54/107, 50.5%) were the most commonly reported hindering factors. The key functions of computer software among eMR users consisted of electronic patient registration system (376/417, 90.2%), drug dispensing system (328/417, 78.7%) and electronic drug labels (296/417, 71.0%). SoftLink Clinic Solution was the most popular vendor (160/417, 38.4%).

Conclusions

These findings identified several physician groups who should be targeted for more assistance on eMR installation and its adoption. Future studies should address the barriers of using Internet-based eMR to enhance its adoption.

The impact of telehealthcare on the quality and safety of care: a systematic overview

BACKGROUND

Telehealthcare involves the use of information and communication technologies to deliver healthcare at a distance and to support patient self-management through remote monitoring and personalised feedback. It is timely to scrutinise the evidence regarding the benefits, risks and costs of telehealthcare.

METHODS AND FINDINGS

Two reviewers searched for relevant systematic reviews published from January 1997 to November 2011 in: The Cochrane Library, MEDLINE, EMBASE, LILACS, IndMed and PakMed. Reviewers undertook independent quality assessment of studies using the Critical Appraisal Skills Programme (CASP) tool for systematic reviews. 1,782 review articles were identified, from which 80 systematic reviews were selected for inclusion. These covered a range of telehealthcare models involving both synchronous (live) and asynchronous (store-and-forward) interactions between provider and patients. Many studies showed no differences in outcomes between telehealthcare and usual care. Several reviews highlighted the large number of short-term (<12 months) feasibility studies with under 20 participants. Effects of telehealthcare on health service indicators were reported in several reviews, particularly reduced hospitalisations. The reported clinical effectiveness of telehealthcare interventions for patients with long-term conditions appeared to be greatest in those with more severe disease at high-risk of hospitalisation and death. The failure of many studies to adequately describe the intervention makes it difficult to disentangle the contributions of technological and human/organisational factors on the outcomes reported. Evidence on the cost-effectiveness of telehealthcare remains sparse. Patient safety considerations were absent from the evaluative telehealthcare literature.

CONCLUSIONS

Policymakers and planners need to be aware that investment in telehealthcare will not inevitably yield clinical or economic benefits. It is likely that the greatest gains will be achieved for patients at highest risk of serious outcomes. There is a need for longer-term studies in order to determine whether the benefits demonstrated in time limited trials are sustained.

Facilitating pediatric patient-provider communications using wireless technology in children and adolescents with sickle cell disease

INTRODUCTION

Use of wireless devices has the potential to transform delivery of primary care services for persons with sickle cell disease (SCD). The study examined text message communications between patients and an advanced practice registered nurse (APRN) and the different primary care activities that emerged with use of wireless technology.

METHODS

Patients (N = 37; mean age 13.9 ± 1.8 years; 45.9% male and 54.1% female) engaged in intermittent text conversations with the APRN as part of the Wireless Pain Intervention Program. Content analyses were used to analyze the content of text message exchanges between patients and the APRN.

RESULTS

The primary care needs that emerged were related to pain and symptom management and sickle cell crisis prevention. Two primary care categories (collaborating and coaching), four primary care subcategories (screening, referring, informing, and supporting), and 16 primary care activities were evident in text conversations.

DISCUSSION

The use of wireless technology may facilitate screening, prompt management of pain and symptoms, prevention or reduction of SCD-related complications, more efficient referral for treatments, timely patient education, and psychosocial support in children and adolescents with SCD.

As Facts and Chats Go Online, What Is Important for Adolescents with Type 1 Diabetes?

Background

Continued refinement of resources for patient information, education and support is needed. Considering the rapid development of new communication practices, the perspectives of young people themselves warrant more attention using a wide research focus. The purpose of this study was to understand information-seeking behaviours, Internet use and social networking online in adolescents with type 1 diabetes (T1DM). This applied to their everyday life, including the context of diabetes and their experiences and need of contact with T1DM peers.

Methodology/Principal Findings

Twenty-four adolescents aged 10–17 years with T1DM were recruited from a county hospital in the south-east of Sweden. Qualitative data were obtained using eight focus groups, wherein each participant engaged in a 60–90 minute video/audio-recorded session. The focus group data were transcribed and analysed using qualitative content analysis. Some demographic and medical information was also collected. The three main categories that were identified; Aspects of Security, Updating, and Plainness and their sub-categories gave significant information about how to enhance information retrieval and peer contacts related to T1DM. Regarding the persons' information-seeking behaviour, Internet use, and use of social media some differences could be identified depending on gender and age.

Conclusions/Significance

Sensitivity and adaptation to users' needs and expectations seem crucial in the development of future online resources for adolescents with T1DM. To start with, this could mean applying a wider range of already existing information and communication technologies. Health practitioners need to focus on the areas of security of information and communication, frequency of updating, and simplicity of design-less is more.

Pumpers, skypers, surfers and texters: technology to improve the management of diabetes in teenagers

A variety of innovative technologies are available to assist with the management of diabetes in teenagers. Technologies include devices that assist with the direct day-to-day management of diabetes including insulin pumps and continuous glucose monitors. These devices are being used more and more with teenagers as a means of improving treatment adherence and glycaemic control. In addition, telehealth is being used to deliver care and support around diabetes management issues for teens with diabetes. Telehealth used in diabetes care for teens includes cell phones and video-conferencing. The goal of this telehealth technology is to support health behaviours and implement behavioural change strategies in a way that is more integrated into the everyday lives of patients and even in the context in which the behaviours occur in 'real time'. Finally, information and support via the Internet are gaining acceptance and use among teens with diabetes as an effective means of strategies for improved diabetes self-care. All three of these broad uses of technology in diabetes in teens represent flexible, innovative, and accessible approaches to improving both diabetes management and glycaemic control in this 'at risk' population.

Telehealth in developmental-behavioral pediatrics

Developmental-behavioral pediatrics (DBP) is recognized as one of the fields with the greatest shortages of pediatric subspecialists. Families who access care often must travel great distances to tertiary academic medical centers or endure long waiting lists. While the shortages are likely to persist due to limited provider availability and an increasing number of children with developmental and behavioral disorders being identified, our field must look to innovative ways to reduce the barriers to access. One such way is telehealth, the use of videoconferencing to deliver DBP services to underserved populations. We aim to describe the practical uses of telehealth for the delivery of diagnostic and management clinical services in a variety of settings and for the additional educational and research benefits of the modality. We will highlight the obstacles to setting up a successful DBP telehealth practice and direct readers to resources to address these in their communities. Most of all, we will demonstrate the benefit to families and children, practitioners, and health care systems of supplementing traditional in-person DBP services with telehealth modalities to enhance outreach and engagement with communities.

The effects of combining Web-based eHealth with telephone nurse case management for pediatric asthma control: a randomized controlled trial

Background

Asthma is the most common pediatric illness in the United States, burdening low-income and minority families disproportionately and contributing to high health care costs. Clinic-based asthma education and telephone case management have had mixed results on asthma control, as have eHealth programs and online games.

Objectives

To test the effects of (1) CHESS+CM, a system for parents and children ages 4–12 years with poorly controlled asthma, on asthma control and medication adherence, and (2) competence, self-efficacy, and social support as mediators. CHESS+CM included a fully automated eHealth component (Comprehensive Health Enhancement Support System [CHESS]) plus monthly nurse case management (CM) via phone. CHESS, based on self-determination theory, was designed to improve competence, social support, and intrinsic motivation of parents and children.

Methods

We identified eligible parent–child dyads from files of managed care organizations in Madison and Milwaukee, Wisconsin, USA, sent them recruitment letters, and randomly assigned them (unblinded) to a control group of treatment as usual plus asthma information or to CHESS+CM. Asthma control was measured by the Asthma Control Questionnaire (ACQ) and self-reported symptom-free days. Medication adherence was a composite of pharmacy refill data and medication taking. Social support, information competence, and self-efficacy were self-assessed in questionnaires. All data were collected at 0, 3, 6, 9, and 12 months. Asthma diaries kept during a 3-week run-in period before randomization provided baseline data.

Results

Of 305 parent–child dyads enrolled, 301 were randomly assigned, 153 to the control group and 148 to CHESS+CM. Most parents were female (283/301, 94%), African American (150/301, 49.8%), and had a low income as indicated by child’s Medicaid status (154/301, 51.2%); 146 (48.5%) were single and 96 of 301 (31.9%) had a high school education or less. Completion rates were 127 of 153 control group dyads (83.0%) and 132 of 148 CHESS+CM group dyads (89.2%). CHESS+CM group children had significantly better asthma control on the ACQ (d = –0.31, 95% confidence limits [CL] –0.56, –0.06, P = .011), but not as measured by symptom-free days (d = 0.18, 95% CL –0.88, 1.60, P = 1.00). The composite adherence scores did not differ significantly between groups (d = 1.48%, 95% CL –8.15, 11.11, P = .76). Social support was a significant mediator for CHESS+CM’s effect on asthma control (alpha = .200, P = .01; beta = .210, P = .03). Self-efficacy was not significant (alpha = .080, P = .14; beta = .476, P = .01); neither was information competence (alpha = .079, P = .09; beta = .063, P = .64).

Conclusions

Integrating telephone case management with eHealth benefited pediatric asthma control, though not medication adherence. Improved methods of measuring medication adherence are needed. Social support appears to be more effective than information in improving pediatric asthma control.

Trial Registration

Clinicaltrials.gov NCT00214383; http://clinicaltrials.gov/ct2/show/NCT00214383 (Archived by WebCite at http://www.webcitation.org/68OVwqMPz)

Effects of clinical communication interventions in hospitals: a systematic review of information and communication technology adoptions for improved communication between clinicians

OBJECTIVE

To conduct a systematic review of the literature to identify, describe and assess interventions of information and communication technology on the processes of communication and associated patient outcomes within hospital settings.

MATERIALS AND METHODS

Studies published from the years 1996 to 2010 were considered and were selected if they described an evaluation of information and communication technology interventions to improve clinical communication within hospitals. Two authors abstracted data from full text articles, and the quality of individual articles were appraised. Results of interventions were summarized by their effect.

RESULTS

There were 18 identified studies that evaluated the use of interventions that included alphanumeric paging, hands-free communication devices, mobile phones, smartphones, task management systems and a display based paging system. Most quantitative studies used a before and after study design and were of lower quality. Of all the studies, there was only one prospective randomized study, but this study used only simulated communication events. Quantitative studies identified improved perceptions of communication and some improvement in communication metrics. Qualitative studies described improvements in efficiency of communication but also issues of loss of control and reliability.

CONCLUSIONS

Despite the rapid advancement in information and communications technology over the last decade, there is limited evidence suggesting improvements in the ability of health professionals to communicate effectively. Given the critical nature of communication, we advocate further evaluation of information and communication technology designed to improve communication between clinicians. Outcome measures should include measures of patient-oriented outcomes and efficiency for clinicians.

Telemedicine for the support of parents of high-risk newborn infants

BACKGROUND

Telemedicine is the use of electronic communications technology to provide care for patients when distance separates the practitioner and the patient. As the parents and families of infants admitted to the NICU require major support from health professionals in terms of information and time, telemedicine has the potential to increase this support.

OBJECTIVES

To evaluate if the use of telemedicine technology to support families of newborn infants receiving intensive care affects the length of hospital stay and parental/family satisfaction.

SEARCH METHODS

We searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, 2011, Issue 8), MEDLINE (from 1966 to September 2011), EMBASE (1980 to September 2011). We also searched ClinicalTrials.gov (http://www.clinicaltrials.gov) and the EudraCT (http://eudract.emea.eu.int) web sites. We searched the proceedings of conferences of the Canadian Society of Telehealth, American Telemedicine Association, the International Society for Telemedicine, the Annual Conference of The International e-Health Association, American Medical Informatics Association and MedInfo.

SELECTION CRITERIA

We attempted to identify randomised controlled trials that assessed the use of telemedicine designed to support parents of infants cared for in a Neonatal Intensive Care Unit (NICU) compared with standard support measures. Our primary outcome was the length of hospital stay, and secondary outcomes included parental and staff satisfaction, emergency hospital visits post-discharge and family utilisation of infant health-related resources.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the studies, extracted the data and assessed the risk of bias of the one included study using the standard methods of the Cochrane Neonatal Review Group. We planned to express treatment effects as risk ratio (RR), risk difference (RD), number needed to treat (NNT) and mean difference (MD) where appropriate, using a fixed-effect model.

MAIN RESULTS

A single study was included for analysis in this review. This study compared the use of telemedicine (Baby Carelink) for parents and families of infants in the NICU with a control group without access to this programme and assessed the length of hospital stay for the infants and family satisfaction in multiple components of infant care. The study shows no difference in the length of hospital stay (average length of stay: telemedicine group: 68.5 days (standard deviation (SD) 28.3 days), control group: 70.6 days (SD 35.6 days), MD -2.10 days (95% confidence interval: -18.85 to 14.65 days). There was insufficient information for further analysis of measures of family satisfaction.

AUTHORS' CONCLUSIONS

There is insufficient evidence to support or refute the use of telemedicine technology to support the parents of high-risk newborn infants receiving intensive care. Clinical trials are needed to assess the application of telemedicine to support parents and families of infants in NICU with length of hospital stay and their perception of NICU care as the major outcomes.

Patient-focused internet interventions in reproductive medicine: a scoping review

BACKGROUND

The Internet has revolutionized fertility care since it became a popular source of information and support for infertile patients in the last decade. The aim of this scoping review is to map (i) the main categories of patient-focused Internet interventions within fertility care, (ii) the detailed composition of the interventions and (iii) how these interventions were evaluated.

METHODS

A literature search used various 'Internet' and 'Infertility' search terms to identify relevant studies published up to 1 September 2011. The selected studies had to include patients facing infertility and using an infertility-related Internet intervention. We charted data regarding categories of interventions, components of interventions and evaluation methodology. We categorized the stages of research using the UK's Medical Research Council framework for evaluating complex interventions.

RESULTS

We included 20 studies and identified 3 educational interventions, 2 self-help interventions, 1 human-supported therapeutic intervention, 9 online support groups and 2 counselling services. Information provision, support and mental health promotion were common aims. Few interactive online components were present in the online programmes. Three studies were in the pilot phase and 17 were in the evaluation phase.

CONCLUSIONS

Several categories of patient-focused Internet-based interventions in fertility care are primarily applied to provide support and education and promote mental health. The interventions could be improved by using more interactive and dynamic elements as their key components. Finally, more emphasis on methodological standards for complex interventions is needed to produce more rigorous evaluations. This review shows where further development or research into patient-focused Internet interventions in fertility-care practice may be warranted.

The impact of nurse short message services and telephone follow-ups on diabetic adherence: which one is more effective?

AIM

To compare the effectiveness of two methods of follow-up: short message service and telephone follow-up on type 2 diabetes adherence for three months.

BACKGROUND

Using telemedicine approaches may preserve appropriate blood glucose levels and may improve adherence to diabetes control recommendations in diabetic patients.

DESIGN

A quasi-experimental, two-group, pretest and post-test design was used in this study to evaluate the effectiveness of nurse's follow-up via cellular phones and telephones.

METHODS

The sample consisted of 77 patients with type 2 diabetes that randomly were assigned to two groups: telephone follow-up (n = 39) and short message service (n = 38). Telephone interventions were applied by a researcher for three months; twice a week for the first month and every week for the second and third month. For three successive months, the short message service group that received messages about adherence to therapeutic regimen was examined. The data gathering instrument included data sheets - to record glycosylated haemoglobin - and the questionnaire related to adherence therapeutic regimen. Data gathering was carried out at the beginning of the study and after three and six months. The data were analysed using descriptive and inferential statistic methods with SPSS version 11.5.

RESULTS

Results showed that both interventions had significant mean changes in glycosylated haemoglobin. For the telephone group (p < 0.001), a mean change of -0.93 and for the short message service group (p < 0.001), a mean change of -1.01. There was no significant difference in diet adherence (p = 0.000), physical exercise (p = 0.000) and medication taking (p = 0.000) adherence in either groups.

CONCLUSION

Intervention using short message services of cellular phones and nurse-led-telephone follow-up improved HbA1c levels and adherence to diabetes therapeutic regimen for three months in type 2 diabetic patients.

RELEVANCE TO CLINICAL PRACTICE

Both of follow-up intervention uses in this study can decrease HbA1c levels and escalate adherence to diabetes control recommendations in people with type 2 diabetes for three months.