Creation of a Patient-Centered Journey Map to Improve the Patient Experience: A Mixed Methods Approach

Perspectives of Healthcare Professionals on Clinician-Patient Communication of Cardiovascular Disease Risk

When the consultation is predominantly verbal, existing research in clinician-patient communication indicates that many patients struggle to understand and recall medical consultations or may not understand the extent of their illness or the purpose of their treatment plan. When the clinician-patient discussion centers around the risk of a repeated cardiovascular disease (CVD) related event, qualitatively assessing what factors affect the communication of this risk may guide the creation of effective communication solutions. Semi-structured interviews were conducted with 17 clinicians treating patients at stages along the cardiac rehabilitation patients' journey. Thematic analysis identified factors that prevent patients from understanding the risk they face of experiencing a repeated cardiac event. Results indicate a clearer understanding of the cardiac rehabilitation patient journey by means of a patient journey map; an overview of how CVD risk is currently communicated; and the factors that affect communication of these risks in the form of themes and sub-themes. Findings shape the proposal of an evidence informed model of opportunities for enhanced digital media supported communication in cardiac rehabilitation.

Involving the Patient and Family in the Transfer of Information at Shift Change in a Pediatric Emergency Department

BACKGROUND

The transfer of information at the change of shift is a critical point for patient experience during the care process. The aim of this study was to evaluate caregivers' perceptions before and after the implementation of a multidisciplinary bedside handoff in a pediatric emergency department (PED).

METHODS

This was a quality improvement pre-post intervention, single-center study. The authors included caregivers of patients allocated in the observation unit of a PED during health care provider shift change. The study was made up of the following phases: (1) preintervention survey distribution, (2) implementation of the bedside handoff, involving all health care professionals (including nurses, nursing assistants, and pediatricians) and caregivers, and (3) postintervention survey distribution. The survey explored the three dimensions of patient experience defined as main study outcomes: information received and communication with professionals, participation, and continuity of care.

RESULTS

A total of 102 surveys were collected (51 each in the preintervention and postintervention phases). In the preintervention phase, 94.1% of caregivers would have wished to be actively involved in the change of shift. In the postintervention phase, more caregivers felt that professionals had proper introductions (49.0% vs. 84.3%; p < 0.01), had kept them informed of the plan to be followed (58.8% vs. 84.3%; p = 0.02), and encouraged questions (45.1% vs. 82.4%; p < 0.01). Caregivers of the postintervention phase perceived less disorganization during the change of shift (25.5% vs. 5.9%; p = 0.01) and a greater sense of continuity (64.7% vs. 86.3%; p = 0.02).

CONCLUSION

The bedside handoff is a useful strategy to improve patient and family perceptions of communication with professionals, information received, and continuity of care at health care providers shift change. Future lines of research and improvement include ensuring equity in participation in the bedside handoff for all caregivers, monitoring the handoffs to determine how often patients/caregivers participate and correct mistakes in information transfer. and exploring professionals' perceptions.

Timing, Indicators, and Approaches to Digital Patient Experience Evaluation: Umbrella Systematic Review

BACKGROUND

The increasing prevalence of DH applications has outpaced research and practice in digital health (DH) evaluations. Patient experience (PEx) was reported as one of the challenges facing the health system by the World Health Organization. To generate evidence on DH and promote the appropriate integration and use of technologies, a standard evaluation of PEx in DH is required.

OBJECTIVE

This study aims to systematically identify evaluation timing considerations (ie, when to measure), evaluation indicators (ie, what to measure), and evaluation approaches (ie, how to measure) with regard to digital PEx. The overall aim of this study is to generate an evaluation guide for further improving digital PEx evaluation.

METHODS

This is a 2-phase study parallel to our previous study. In phase 1, literature reviews related to PEx in DH were systematically searched from Scopus, PubMed, and Web of Science databases. Two independent raters conducted 2 rounds of paper screening, including title and abstract screening and full-text screening, and assessed the interrater reliability for 20% (round 1: 23/115 and round 2: 12/58) random samples using the Fleiss-Cohen coefficient (round 1: k1=0.88 and round 2: k2=0.80). When reaching interrater reliability (k>0.60), TW conducted the rest of the screening process, leaving any uncertainties for group discussions. Overall, 38% (45/119) of the articles were considered eligible for further thematic analysis. In phase 2, to check if there were any meaningful novel insights that would change our conclusions, we performed an updated literature search in which we collected 294 newly published reviews, of which 102 (34.7%) were identified as eligible articles. We considered them to have no important changes to our original results on the research objectives. Therefore, they were not integrated into the synthesis of this review and were used as supplementary materials.

RESULTS

Our review highlights 5 typical evaluation objectives that serve 5 stakeholder groups separately. We identified a set of key evaluation timing considerations and classified them into 3 categories: intervention maturity stages, timing of the evaluation, and timing of data collection. Information on evaluation indicators of digital PEx was identified and summarized into 3 categories (intervention outputs, patient outcomes, and health care system impact), 9 themes, and 22 subthemes. A set of evaluation theories, common study designs, data collection methods and instruments, and data analysis approaches was captured, which can be used or adapted to evaluate digital PEx.

CONCLUSIONS

Our findings enabled us to generate an evaluation guide to help DH intervention researchers, designers, developers, and program evaluators evaluate digital PEx. Finally, we propose 6 directions for encouraging further digital PEx evaluation research and practice to address the challenge of poor PEx.

Methadone for Emergence Delirium in Ambulatory Pediatric Strabismus Surgery

Background: Emergence delirium in children following strabismus surgery is a distressing and potentially dangerous condition and is likely attributable to visual disturbances, pain, and anesthetic gases. We explored whether a single intraoperative dose of methadone could reduce emergence delirium. Methods: Our study was an institutional review board-approved prospective, controlled, before-and-after investigation. Inclusion criteria were age <18 years and American Society of Anesthesiologists (ASA) classification 1 or 2. Patients were excluded for obesity, documented sleep apnea, significant neurologic disease, or inpatient status. Control group patients were recruited sequentially, and the anesthetic was performed per preference. The study group was recruited similarly and received an intravenous dose of methadone 0.15 mg/kg at induction. The primary outcome was peak score on the Pediatric Anesthesia Emergence Delirium (PAED) scale. Secondary outcomes included time to anesthetic emergence, postoperative pain scores, postanesthesia care unit (PACU) length of stay, and postdischarge respiratory complications. Results: Forty-nine control group and 55 study group patients were recruited. No significant differences were found between groups for age, sex, weight, ASA classification, or duration of surgery. The control group received more preoperative midazolam, intraoperative fentanyl, and intraoperative ketorolac. Compared to the control group, the study group had 42% and 85% reductions in peak and severe PAED scale scores, respectively, in the PACU and required less rescue pain medications. Anesthetic emergence time and length of stay were not different between the groups. No significant postoperative complications occurred. Conclusion: Emergence delirium following outpatient pediatric strabismus surgery was substantially mitigated by the use of intraoperative methadone without affecting PACU throughput. No significant complications occurred. Further study is warranted to corroborate routine use of this drug for emergence delirium.

Opportunities to improve asthma and COPD prevention and care: insights from the patient journey obtained through focus groups

BACKGROUND

The healthcare experiences of patients hold valuable insights for improving the quality of services related to their well-being. We therefore invited and explored the perspectives of patients living with asthma and chronic obstructive pulmonary disease (COPD) on their interaction with the systems supporting health, in order to identify opportunities to improve services to prevent, treat and manage these conditions.

METHODS

Two virtual focus groups were held in August 2021, one for adult asthma and one for COPD, to learn of patients' experiences receiving care for these conditions in the Vancouver Coastal Health (VCH) region of British Columbia. Participants were recruited through online postings or their clinician. We discussed the care pathway for each condition and invited participants to share their experiences of the past 5 years, specifically their reflections on the process, including feelings, points of praise and frustration, and opportunities for improvement in this context. Composite patient journey maps were developed for each condition to reflect the experiences shared. Audio recordings of the focus groups were transcribed and used in qualitative data analysis.

RESULTS

Thematic analysis revealed the following as possible areas for improvement: low public awareness of asthma and COPD and associated risk factors, non-standardised diagnosis pathways that delay diagnosis, and inconsistency in delivering valued aspects of care such as supports for self-management, trust-inspiring acute care, empowering patient communication and timely access to care.

CONCLUSION

We successfully used focus groups to generate composite journey maps of the experiences of patients living with asthma (n=8) and COPD (n=9) to identify features that these patients consider important for improving the healthcare system for asthma and COPD in VCH. Health professionals, decision makers and patient advocates in VCH and beyond can consider these insights when evaluating, and planning changes to, current practices and policies in service delivery.

Facilitators of and barriers to perinatal telepsychiatry care: a qualitative study

OBJECTIVES

Perinatal mental health disorders such as anxiety, depression and bipolar disorder can negatively impact the health of women and their children without appropriate detection and treatment. Due to increases in mental health symptoms and transmission risks associated with in-person appointments, many clinics transitioned to providing telepsychiatry care during the COVID-19 pandemic. This study sought to identify the facilitators and barriers to receiving perinatal telepsychiatry care from the perspective of patients, clinic staff and psychiatrists.

DESIGN

Qualitative study based on analysis of in depth semistructured interviews.

SETTING

The study was conducted in a virtual specialty mental health clinic in an academic setting.

PARTICIPANTS

Eight patients who had been scheduled for an appointment with the perinatal telepsychiatry clinic between 14 May 2021 and 1 August 2021, seven of whom had attended their scheduled appointment with the clinic and one of whom had not, and five staff members including psychiatrists, navigators and clinic managers, participated in in-depth interviews.

RESULTS

Telepsychiatry was perceived by most as preferable to in-person care and easy to attend and navigate. Alternatively, technological difficulties, personal preference for in-person care and scheduling conflicts related to the perinatal period were identified as barriers by some. Participants identified communication between care staff and patients, online patient portals, and appointment reminders as important for facilitating appointment preparedness and attendance.

CONCLUSIONS

The findings from this study suggest that telepsychiatry services are perceived positively by patients and care staff and have the potential to improve access to mental healthcare for perinatal patients.

Work-focused healthcare from the perspective of employees living with cardiovascular disease: a patient experience journey mapping study

BACKGROUND

People living with cardiovascular diseases (CVD) often experience work participation problems. Good work-focused healthcare, defined as the received advice, treatment, and guidance focusing on work participation, can support the patient and work place. However, experiences with work-focused healthcare are generally not always positive which is a barrier for work participation. Therefore, the objective of this study is to gain insight into the work-focused healthcare journey from the perspective of patients with work participation problems due to CVD, to understand their experiences and needs, and to derive opportunities for improving work-focused healthcare service at a system level.

METHODS

Semi-structured interviews, preceded by preparatory assignments, were conducted with 17 patients who experience(d) work participation problems due to CVD. The patient experience journey map (PEJM) approach was used to visualize the patients' work-focused healthcare journey, including experiences and needs over time and place, from which opportunities to improve work-focused healthcare from the patient's perspective were derived.

RESULTS

An aggregated PEJM consisting of six phases was composed and graphically mapped. The first phase, working, represents a period in which CVD health problems and subsequent functional limitations occur. The next two phases, short- and long-term sick leave, represent a period of full sick leave. The last three phases, start-, partial-, and full vocational reintegration, focus on the process of return to work that takes place ranging from a few months up to several years after sick-listing. For each phase the touchpoints, timespan, stakeholders, activities, experiences and needs from the perspective of the patients were identified. Finally, for better work-focused healthcare nine opportunities for improvement were derived from the PEJM, e.g. emphasize the need for work adjustment prior to the medical intervention, provide more personalized advice on handling work limitations, and putting more compelling pressure on the employer to create suitable work positions for their employees.

DISCUSSION/CONCLUSION

This paper contributes insights to provide a more patient-centered work-focused healthcare trajectory for patients employed in paid jobs when living with CVD. The PEJM provides an understanding of the patients' perspectives throughout their work-focused healthcare journey and highlights opportunities for improvement towards a better suited and seamless patient journey, Although this research was conducted within the Dutch healthcare system, it can be assumed that the findings on integrated work-focused healthcare are largly transferable to other healthcare systems.

An integrative review of human-centered design and design thinking for the creation of health interventions

BACKGROUND

In the United States, we have a healthcare system crisis with high rates of dissatisfaction among patients and providers. To transform health and healthcare, clinical providers must be proficient in the human-centered approach of design thinking (DT).

OBJECTIVE

To synthesize the human-centered design (HCD) and DT literature for the creation of health interventions.

METHODS

We performed an integrative literature review focused on how HCD and DT are used in the clinical healthcare setting. Four research databases were searched from inception through November 6, 2020. We analyzed the methodology used, who is using the frameworks, and the DT phases included.

RESULTS

Twenty-four articles were included in the final analysis. Of the 24 manuscripts, 6 (25%) were nurse-led and 15 (63%) had interdisciplinary first and last authors (e.g., Nursing and Medicine). Overall, 10/24 (42%) included all DT method. When analyzing the articles by approach or methodology, 12 (50%) stated they were using the HCD approach, 5 (21%) the DT methodology, and 7 (29%) stated they were using both the HCD approach and DT methodology.

CONCLUSION

There are inconsistencies in who uses DT and the phases used to create healthcare interventions.

The road to patient-centred care in Peru: The difficulties and opportunities to achieve participatory health care

Patient-centred care (PCC) is a pillar of quality health services, where decision-making power is shared between the clinician and the patient. Although, this approach could be adopted with easiness in high income settings or in countries with unified health systems, in settings such as Peru, where universal access and other structural problems remain a challenge, the practice of PCC is not a priority. In Peru, research on PCC has been conducted for almost two decades, but this has not generated a need for development in academia, decision makers, health personnel or patients. Here, we give an overview of the road that PCC research has taken in Peru and the challenges that remain to translate it into clinical practice.

Creation of a Multispecialty Clinic for Patients with Central Sensitization-Based Chronic Pain Conditions

Objective

To design and evaluate, through a human-centered design approach, a multispeciality clinic for patients with central sensitization syndromes that combined virtual previsit consultations, traditional face-to-face appointments, and technology-enabled educational programming.

Patients and Methods

Patients with suspected fibromyalgia and chronic abdominal pain were seen in a multispecialty practice, and the performance of the clinic was evaluated against a contemporary cohort. Quantitative and qualitative evaluation measures included team estimates of time spent on care-related tasks, physician rank of alignment of patient need with clinic design, major appointment changes, and nonvisit care tasks. Members of the care team also evaluated strengths, weaknesses, opportunities, and threats to the success of the clinic.

Results

The pilot clinic was operated from April 1, 2020, to April 30, 2021, and included 34 patients with suspected fibromyalgia/chronic abdominal pain. During the pilot period, physicians ranked the value of the virtual previsit consultations in providing care as 7.5 on a scale of 0 to 10 and reported an average of 50 minutes in preparation for the appointment, execution of the appointment, and postvisit documentation. We did not observe substantial differences in the number of added appointments or messages received within the patient portal when compared with a comparison cohort. Patients who participated in the combination nurse educator–led and digital education program provided positive feedback about their experience.

Conclusion

Our clinic model provides a framework for the treatment of patients with debilitating centrally sensitized conditions and future expansion of virtual care delivery models to better meet patient care and educational needs.

A hybrid method of healthcare delivery research and human-centered design to develop technology-enabled support for caregivers of hematopoietic stem cell transplant recipients

Health information technology (HIT) is a widely recognized strategy to encourage cancer patients and caregivers to participate in healthcare delivery in a sustainable and cost-effective way. In the context of autologous hematopoietic cell transplant (HSCT), HIT-enabled tools have the potential to effectively engage, educate, support, and optimize outcomes of patients and caregivers in the outpatient setting. This study sought to leverage human-centered design to develop a high-fidelity prototype of a HIT-enabled psychoeducational tool for HSCT caregivers. Phase 1 focuses on breadth and depth of information gathering through a systematic review and semi-structured interviews to determine optimal tool use. Phase 2 engages in human-centered design synthesis and visualization methods to identify key opportunities for the HIT design. Phase 3 employs human-centered design evaluation, engaging caregivers to respond to low-fidelity concepts and scenarios to help co-design an optimal tool for HSCT. This study outlines a hybrid method of healthcare delivery research and human-centered design to develop technology-enabled support for HSCT caregivers. Herein, we present a design methodology for developing a prototype of HIT-enabled psychoeducational tool which can be leveraged to develop future eHealth innovations to optimize HSCT.

Using journey mapping to understand the patient experience with selecting a Medicare part D plan using a pharmacy consultation service

Background

Patient experience with community pharmacy services can be informed by human-centered design principles and approaches. Pharmacy services may benefit from detailed evaluations of consumer experience and patient-centered service design.

Objectives

To use an online journey mapping platform to understand the patient experience with selecting a Medicare Part D plan for individuals that did, and did not, use a free, pharmacy-led, Medicare Part D consultation service.

Methods

This was a two-group cross-sectional survey study in a single, rural community pharmacy. Surveys consisted of 7 demographic items, 30 Likert-type items, and 7 open-ended response items. The pharmacy used purposeful convenience sampling to distribute a paper survey to individuals 65 years of age and older currently enrolled in Medicare Part D between June and August 2019. Surveys were distributed to 36 patients currently enrolled in a Medicare Part D plan, with 18 surveys distributed to patients who had previously used a pharmacy-led Medicare Part D consultation service and 18 surveys distributed to patients who did not use the service. Surveys were uploaded to an online journey mapping platform, producing data visualizations for each group. Multiple choice survey items were analyzed using descriptive statistics, wth service user and nonuser groups compared using Mann-Whitney U tests. Open-ended survey responses were coded by the research team using an inductive approach.

Results

In total, 36 surveys were returned to the community pharmacy for a response rate of 100%. The journey map platform generated Persona, Empathy, and Current Journey outputs, which mapped Good Experiences and Bad Experiences within the Medicare Part D plan selection experience. Personas differed in their median household incomes ($25,000–$39,999 for service users compared to $50,000–$74,999 for nonusers). Empathy and Current Journey outputs showed that service users had a wider variety of emotions compared to non-users. Mann-Whitney U tests yielded 5 items with statistically significant differences (p-values <0.05) in the plan-selection experience, with both groups similarly uncertain about their plan decision. Qualitative responses indicate patient trust was universally important to a complex decision-making process.

Conclusions

An online journey mapping platform provided insight into how patients experience a pharmacy service that extends beyond satisfaction. For community pharmacies providing Medicare Part D plan consultation services, pharmacies should consider how they can improve the service experience through communication style and patient-centered service design.

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Design Think practices like journey mapping may aid in patient-centered service design.

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The elaboration likelihood model (ELM) may help to explain patient experience with a Medicare Part D consultation service with Medicare

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Information processing ability and heuristics may influence patient decisions.

Helpfulness of Clinical Visit Summary Content From Multi-Specialty Care: A Mixed-Methods Assessment

Objective:

We surveyed patients who visited multiple outpatient specialty practices to understand what summary content was most helpful with the goal of optimizing meaningful outpatient clinical visit summary content.

Materials and Methods:

We constructed a survey instrument to measure delivery, use, and contents of clinical visit summaries. We surveyed patients who visited with at least 2 different outpatient medical specialties to understand preferences.

Results:

Most patients in our sample valued the summary information they received, and retained it as healthcare documentation (84%) and/or quick reference in supporting self-care (70%). Patients most commonly reported that information on results of completed tests (91%) and treatment plan instructions (89%) were very helpful. Additionally, patients expressed the importance of online access to clinical visit summary information.

Discussion:

Most patients used the clinical visit summary as healthcare documentation, and valued online availability of their summary information. Patients most often reported that information on results of recently completed tests and specific instructions on treatment plan were very helpful. Patients who sought further information after their visit most often looked to a provider and/or online.

Conclusions:

Patients valued clinical visit summary accessibility and as a reference tool to summarize care and provide next steps. Optimal clinical visit summaries might collate and integrate assessments and recommendations from multiple specialties into coherent care plans for patients.