Requirements for an Electronic Health Tool to Support the Process of Help Seeking by Caregivers of Functionally Impaired Older Adults: Co-Design Approach

Older Persons' and Health Care Professionals' Design Choices When Co-Designing a Medication Plan Aiming to Promote Patient Safety: Case Study

BACKGROUND

Harm from medications is a major patient safety challenge among older persons. Adverse drug events tend to arise when prescribing or evaluating medications; therefore, interventions targeting these may promote patient safety. Guidelines highlight the value of a joint plan for continued treatment. If such a plan includes medications, a medication plan promoting patient safety is advised. There is growing evidence for the benefits of including patients and health care professionals in initiatives for improving health care products and services through co-design.

OBJECTIVE

This study aimed to identify participants' needs and requirements for a medication plan and explore their reasoning for different design choices.

METHODS

Using a case study design, we collected and analyzed qualitative and quantitative data and compared them side by side. We explored the needs and requirements for a medication plan expressed by 14 participants (older persons, nurses, and physicians) during a co-design initiative in a regional health system in Sweden. We performed a directed content analysis of qualitative data gathered from co-design sessions and interviews. Descriptive statistics were used to analyze the quantitative data from survey answers.

RESULTS

A medication plan must provide an added everyday value related to safety, effort, and engagement. The physicians addressed challenges in setting aside time to apply a medication plan, whereas the older persons raised the potential for increased patient involvement. According to the participants, a medication plan needs to support communication, continuity, and interaction. The nurses specifically addressed the need for a plan that was easy to gain an overview of. Important function requirements included providing instant access, automation, and attention. Content requirements included providing detailed information about the medication treatment. Having the plan linked to the medication list and instantly obtainable information was also requested.

CONCLUSIONS

After discussing the needs and requirements for a medication plan, the participants agreed on an iteratively developed medication plan prototype linked to the medication list within the existing electronic health record. According to the participants, the medication plan prototype may promote patient safety and enable patient engagement, but concerns were raised about its use in daily clinical practice. The last step in the co-design framework is testing the intervention to explore how it works and connects with users. Therefore, testing the medication plan prototype in clinical practice would be a future step.

Developing A Mobile App With a Human-Centered Design Lens to Improve Access to Mental Health Care (Mentallys Project): Protocol for an Initial Co-Design Process

BACKGROUND

Co-design is one of the human-centered design approaches that allows end users to significantly and positively impact the design of mental health technologies. It is a promising approach to foster user acceptance and engagement in digital mental health solutions. Surprisingly, there is a lack of understanding of what co-design is in this field. In this paper, co-design is approached as a cocreation process involving persons with a lived experience of mental health problems, health professionals, and design experts who lead and facilitate the overall creative process.

OBJECTIVE

This paper describes an initial co-design research protocol for the development of a mobile app that aims to improve access to mental health care. It highlights the characteristics of a co-design approach in e-mental health rooted in human-centered design and led by design experts alongside health experts. The paper focuses on the first steps (phase 1) of the co-design process of the ongoing Mentallys project.

METHODS

This Mentallys project will be located in Montréal (Quebec, Canada). The method approach will be based on the "method stories," depicting the "making of" this project and reflecting adjustments needed to the protocol throughout the project in specific situations. Phase 1 of the process will focus on the desirability of the app. Targeted participants will include people with a lived experience of mental health problems, peer support workers and clinicians, and 3 facilitators (all design experts or researchers). Web-based sessions will be organized because of the COVID-19 pandemic, using Miro (RealtimeBoard Inc) and Zoom (Zoom Video Communications, Inc). Data collection will be based on the comments, thoughts, and new ideas of participants around the imaginary prototypes. Thematic analysis will be carried out after each session to inform a new version of the prototype.

RESULTS

We conducted 2 stages in phase 1 of the process. During stage 1, we explored ideas through group co-design workshops (divergent thinking). Six co-design workshops were held: 2 with only clinicians (n=7), 2 with peer support workers (n=5) and people with a lived experience of mental health problems (n=2), and 2 with all of them (n=14). A total of 6 facilitators participated in conducting activities in subgroups. During stage 2, ideas were refined through 10 dyad co-design sessions (convergent thinking). Stage 2 involved 3 participants (n=3) and 1 facilitator. Thematic analysis was performed after stage 1, while analytic questioning is being performed for stage 2. Both stages allowed several iterations of the prototypes.

CONCLUSIONS

The design of the co-design process, the leadership of the design expertise throughout the process, and the different forms of co-design activities are key elements in this project. We highly recommend that health researchers partner with professional designers or design researchers who are familiar with co-design.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/47220.

Co-Design of a Financial and Legal Planning Tool for Care Partners of People Living With Alzheimer's Disease and Related Dementias

Background and Objectives

Care partners of people living with Alzheimer's disease and related dementias (ADRD) are faced with substantial legal and financial planning related to their care partner role. However, many care partners lack the legal and financial support needed to manage this role. The purpose of this study was to engage ADRD care partners in a remote participatory design process to create a technology-based financial and legal planning tool that meets care partner needs.

Research Design and Methods

We formed 2 researcher-facilitated co-design teams comprised of n = 5 ADRD care partners each. We conducted a series of 5 parallel co-design sessions aimed to engage co-designers in interactive discussions and design activities to create the financial and legal planning tool. We used inductive thematic analysis of design session recordings to identify design requirements.

Results

Co-designers were 70% female with a mean age of 67.3 years (standard deviation 9.07) and cared for a spouse (80%) or a parent (20%). Between Sessions 3 and 5, the average system usability scale score of the prototype increased from 89.5 to 93.6, indicating high usability. Analyses yielded 7 overarching design requirements for a legal and financial planning tool: support for action now (eg, prioritized to-do lists); support for action later (eg, reminders for keeping legal documents up-to-date); knowledge when I need it (eg, tailored learning modules); connection to resources I need (eg, state-specific financial support opportunities); everything where I can see it (eg, comprehensive care budgeting tool); sense of privacy and security (eg, password protection); and accessibility for all (eg, tailoring for low-income care partners).

Discussion and Implications

The design requirements identified by co-designers provide a foundation from which we can build technology-based solutions to support ADRD care partners in financial and legal planning.

An "ultimate partnership": Older persons' perspectives on age-stereotypes and intergenerational interaction in co-designing digital technologies

AIM

There is often a gap between the ideal of involving older persons iteratively throughout the design process of digital technology, and actual practice. Until now, the lens of ageism has not been applied to address this gap. The goals of this study were: to voice the perspectives and experiences of older persons who participated in co-designing regarding the design process; their perceived role in co-designing and intergenerational interaction with the designers; and apparent manifestations of ageism that potentially influence the design of digital technology.

METHODS

Twenty-one older persons participated in three focus groups. Five themes were identified using thematic analysis which combined a critical ageism 'lens' deductive approach and an inductive approach.

RESULTS

Ageism was experienced by participants in their daily lives and interactions with the designers during the design process. Negative images of ageing were pointed out as a potential influencing factor on design decisions. Nevertheless, positive experiences of inclusive design pointed out the importance of "partnership" in the design process. Participants defined the "ultimate partnership" in co-designing as processes in which they were involved from the beginning, iteratively, in a participatory approach. Such processes were perceived as leading to successful design outcomes, which they would like to use, and reduced intergenerational tension.

CONCLUSIONS

This study highlights the potential role of ageism as a detrimental factor in how digital technologies are designed. Viewing older persons as partners in co-designing and aspiring to more inclusive design processes may promote designing technologies that are needed, wanted and used.

User Experience of the Co-design Research Approach in eHealth: Activity Analysis With the Course-of-Action Framework

Background

The cocreation of eHealth solutions with potential users, or co-design, can help make the solution more acceptable. However, the co-design research approach requires substantial investment, and projects are not always fruitful. Researchers have provided guidelines for the co-design approach, but these are either applicable only in specific situations or not supported by empirical data. Ways to optimize the experience of the co-design process from the point of view of the participants are also missing. Scientific literature in the co-design field generally provides an extrinsic description of the experience of participants in co-design projects.

Objective

We addressed this issue by describing a co-design project and focusing on the participants’ experiences looking at what was significant from their point of view.

Methods

We used a qualitative situated cognitive anthropology approach for this study. Data were collected on a co-design research project that aimed to support the help-seeking process of caregivers of functionally dependent older adults. The methodology was based on the perspective of experience by Dewey and used the course-of-action theoretical and methodological framework. Data collection was conducted in 2 phases: observation of participants and recording of sessions and participant self-confrontation interviews using the session recordings. We interviewed 27% (20/74) of the participants. We analyzed the data through nonexclusive emerging categorization of themes using the constant comparative method.

Results

In total, 5 emerging themes were identified. The perception of extrinsic constraints and the effects of the situation was central and the most important theme, affecting other themes (frustrating interactions with others, learning together, destabilization, and getting personal benefits). Co-occurrences between codes allowed for a visual and narrative understanding of what was significant for the participants during this project. The results highlighted the importance of the role of the research team in preparing and moderating the sessions. They also provided a detailed description of the interactions between participants during the sessions, which is a core aspect of the co-design approach. There were positive and negative aspects of the participants’ experiences during this co-design project. Reflecting on our results, we provided potential affordances to shape the experience of participants in co-design.

Conclusions

Potential users are an essential component of the co-design research approach. Researchers and designers should seek to offer these users a positive and contributory experience to encourage participation in further co-design initiatives. Future research should explore how the proposed affordances influence the success of the intervention.

How and how well have older people been engaged in healthcare intervention design, development or delivery using co-methodologies: A scoping review with narrative summary

Co-methodological working is gaining increasing traction in healthcare, but studies with older people have been slower to develop. Our aim was to investigate how and how well older people have been engaged in healthcare intervention design, development or delivery using co-methodologies. We conducted a systematic search of four electronic databases to identify international literature published between 2009 and November 2019. We included peer-reviewed empirical research of any design. Three authors screened papers. Our review is reported in accordance with the Joanna Briggs Institute manual for scoping reviews, we have referred to the preferred reporting items for systematic reviews and meta-analyses statement. We data extracted to a bespoke spreadsheet and used the Co:Create Co-production Matrix to guide quality appraisal. Included studies (n = 48) were diverse in nature of interventions, co-methodologies and reporting. We offer a narrative summary of included papers. Establishing how older people were engaged in co-methodological work was largely straightforward. How well this was done was more challenging, however we have identified gems of good practice and offered directions for future practice. The Co:Create Co-Production Matrix was the best fit for evaluating papers, however it is not intended as a measure per se. In essence we argue that notions of 'best' and 'scores' are an oxymoron in co-methodological working, what is important that: (a) researchers embrace these methods, (b) incremental change is the way forward, (c) researchers need to do what is right for people and purpose and (d) have time to consider and articulate why they are choosing this approach and how best this can be achieved for their particular situation. Future evaluation of participant's experience of the process would enable others to learn about what works for who and in what circumstances.

Adoption Intention and Factors Influencing the Use of Gerontechnology in Chinese Community-Dwelling Older Adults: A Mixed-Methods Study

Objective: To explore the Chinese community-dwelling intention of older adults to adopt gerontechnology and its influencing factors.

Design: A mixed-methods sequential explanatory design with an inductive approach was employed. In phase 1, a self-made questionnaire was administered from August 2018 to December 2019. Multifactor logistic regression was used to analyze the adoption intention and factors influencing the use of gerontechnology. In phase 2, participants completed a semistructured interview to explore the adoption intention of a specific form of gerontechnology, Smart Aged Care Platform, from May to July 2020.

Setting: Twelve communities in three districts of Chongqing, China.

Participants: Community-dwelling older adults were included.

Results: A total of 1,180 older adults completed the quantitative study; two-thirds of them (68.7%) showed adoption intention toward gerontechnology. Nineteen participants (10 users and nine nonusers) completed the qualitative study and four themes were explored. Through a summarized understanding of the qualitative and quantitative data, a conceptual model of influencing factors, namely, predictive, enabling, and need factors, was constructed.

Conclusions: This study reveals that most Chinese community-dwelling older adults welcome the emergence of new technologies. However, there was a significant difference in the adoption intention of gerontechnology in Chinese community-dwelling older adults based on their sociodemographic and psychographic characteristics. Our findings extend previous technology acceptance models and theories and contribute to the existing resource base.

Usability of a Co-designed eHealth Prototype for Caregivers: Combination Study of Three Frameworks

Background

Co-design (or the participation of users) has shown great potential in the eHealth domain, demonstrating positive results. Nevertheless, the co-design approach cannot guarantee the usability of the system designed, and usability assessment is a complex analysis to perform, as evaluation criteria will differ depending on the usability framework (or set of criteria) used. ISO (International Organization for Standardization) on usability (ISO 9241-210), Nielsen heuristic, and Garrett element of user experience inform different yet complementary aspects of usability.

Objective

This study aims to assess the usability and user experience of a co-design prototype by combining 3 complementary frameworks.

Methods

To help caregivers provide care for functionally impaired older people, an eHealth tool was co-designed with caregivers, health and social service professionals, and community workers assisting caregivers. The prototype was a website that aims to support the help-seeking process for caregivers (finding resources) and allow service providers to advertise their services (offering resources). We chose an exploratory study method to assess usability in terms of each objective. The first step was to assess users’ first impressions of the website. The second was a task scenario with a think-aloud protocol. The final step was a semistructured interview. All steps were performed individually (with a moderator) in a single session. The data were analyzed using 3 frameworks.

Results

A total of 10 participants were recruited, 5 for each objective of the website. We were able to identify several usability problems, most of which were located in the information design and interface design dimensions (Garrett framework). Problems in both dimensions were mainly coded as effectiveness and efficiency (ISO framework) and error prevention and match between the systemand the real world (Nielsen heuristic).

Conclusions

Our study provided a novel contribution about usability analysis by combining the 3 different models to classify the problems found. This combination provided a holistic understanding of the usability improvements needed. It can also be used to analyze other eHealth products.

International Registered Report Identifier (IRRID)

RR2-10.2196/11634

A Systematic Review of Design Workshops for Health Information Technologies

Background: Design workshops offer effective methods in eliciting end-user participation from design inception to completion. Workshops unite stakeholders in the utilization of participatory methods, coalescing in the best possible creative solutions. Objective: This systematic review aimed to identify design approaches whilst providing guidance to health information technology designers/researchers in devising and organizing workshops. Methods: A systematic literature search was conducted in five medical/library databases identifying 568 articles. The initial duplication removal resulted in 562 articles. A criteria-based screening of the title field, abstracts, and pre-full-texts reviews resulted in 72 records for full-text review. The final review resulted in 10 article exclusions. Results: 62 publications were included in the review. These studies focused on consumer facing and clinical health information technologies. The studied technologies involved both clinician and patients and encompassed an array of health conditions. Diverse workshop activities and deliverables were reported. Only seven publications reported workshop evaluation data. Discussion: This systematic review focused on workshops as a design and research activity in the health informatics domain. Our review revealed three themes: (1) There are a variety of ways of conducting design workshops; (2) Workshops are effective design and research approaches; (3) Various levels of workshop details were reported.

Opportunities and Challenges of a Self-Management App to Support People With Spinal Cord Injury in the Prevention of Pressure Injuries: Qualitative Study

BACKGROUND

Mobile health applications can offer tailored self-management support to individuals living with chronic health conditions. However, there are several challenges to the adoption of these technologies in practice. Co-design is a promising approach to overcoming some of these challenges by enabling the development of solutions that meet the actual needs and preferences of the relevant stakeholder groups.

OBJECTIVE

Taking spinal cord injury as a case in point, the overall objectives of this study were to identify the perceived benefits of a co-designed self-management app that could promote its uptake and to explore the factors that may impede adoption.

METHODS

We adopted a qualitative research approach guided by the Technology Acceptance Model. Data were collected through semistructured interviews with individuals with spinal cord injury (n=15) and two focus groups with health care professionals specialized in spinal cord injury (n=7, n=5). Prior to the interviews and focus groups, study participants were given time to explore the app prototype. All interviews were transcribed verbatim and analyzed using inductive thematic analysis.

RESULTS

Findings of our analysis indicate that study participants perceived the app prototype as potentially useful for supporting individuals with spinal cord injury in preventing pressure injuries. In particular, we identified three concrete use cases highlighting the benefits of the app for different audiences: (1) a companion for newly injured individuals, (2) an emergency kit and motivational support, and 3) a guide for informal caregivers and family members. We also uncovered several challenges that might impede the adoption of the self-management app in practice, including (1) challenges in motivating individuals to use the app, (2) concerns about the misuse and abuse of the app, and (3) organizational and maintenance challenges.

CONCLUSIONS

This study adds to a growing body of research that investigates individuals' adoption and nonadoption behavior regarding mobile health solutions. Building on earlier work, we make recommendations on how to address the barriers to the adoption of mobile health solutions identified by this study. In particular, there is a need to foster trust in mobile health among prospective users, including both patients and health care professionals. Moreover, increasing personal relevance of mobile health solutions through personalization may be a promising approach to promote uptake. Last but not least, organizational support also plays an instrumental role in mobile health adoption. We conclude that even though co-design is promoted as a promising approach to develop self-management tools, co-design does not guarantee adoption. More research is needed to identify the most promising strategies to promote the adoption of evidence-based mobile health solutions in practice.

Electronic clinical decision support to facilitate a change in clinical practice: Small details can make or break success

BACKGROUND

The use of electronic clinical decision support (CDS) is becoming common to change historically common clinical practices considered outdated by current guidelines. Preimplementation design of CDS tools is key to their success in changing clinical behaviors. Unfortunately, there are no established protocols for CDS tool development, and CDS failure can result from even small design flaws. This paper describes an example of a design oversight and how correction resulted in CDS success.

STUDY DESIGN AND METHODS

We performed a retrospective review of compliance with a CDS tool to encourage the use of prothrombin complex concentrate over plasma transfusion for the emergent reversal of warfarin. We identified a potential design flaw, made the necessary modifications, and repeated the compliance review.

RESULTS

After CDS, plasma orders declined by 150 units/mo; however, 48% of orders placed for non-warfarin coagulopathy were still for warfarin reversal. Hospital-wide, this noncompliance was 36% and was 80% in the emergency department. By simply relocating the qualifier "NOT on warfarin" from the end to the beginning of the order, noncompliance for warfarin reversal was reduced to 5% (P < .0001 by chi-square).

CONCLUSIONS

The successful use of electronic clinical decision support in the electronic medical record can depend on optimal design. Missing even small design elements such as the positioning of key terms within the tool can result in an ineffective CDS. Important design strategies to avoid poor performance are discussed as they relate to the CDS tool we describe.

Promoting Identification and Use of Aid Resources by Caregivers of Seniors: Co-Design of an Electronic Health Tool

BACKGROUND

The importance of supporting caregivers is recognized in home care for older persons, and facilitating their help-seeking process is a way to meet that need. The use of electronic health (eHealth) is a potentially promising solution to facilitate caregivers' help-seeking process.

OBJECTIVE

The aim of this research was to develop, in partnership with community organizations, health and social service professionals and caregivers, an eHealth tool promoting the earlier identification of needs of older persons and an optimal use of available resources.

METHODS

To design the tool, 8 co-design sessions (CoDs) were conducted and 3 advisory committees were created (in 11 regions) in Quebec between May 2017 and May 2018. A variety of methods were used, including the sorting method, the use of personas, eHealth tool analysis, brainstorming, sketching, prototyping, and pretesting.

RESULTS

A total of 74 co-designers (women n=64 and men n=10) were recruited to participate in the CoDs or the advisory committees. This number allowed for the identification of needs to which the tool must respond and for the identification of its requirements (functionalities and content), as well as for the development of the information architecture. Throughout the study, adjustments were made to the planning of CoD, notably because certain steps required more sessions than expected. Among others, this was true for the identification of functionalities.

CONCLUSIONS

This study led to the development of an eHealth tool for caregivers of functionally dependent older persons to help them identify their needs and the resources available to meet them.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/11634.