The Effectiveness of Information Technology-Supported Shared Care for Patients With Chronic Disease: A Systematic Review

Electronic health record and primary care physician self-reported quality of care: a multilevel study in China

BACKGROUND

Health information technology is one of the building blocks of a high-performing health system. However, the evidence regarding the influence of an electronic health record (EHR) on the quality of care remains mixed, especially in low- and middle-income countries.

OBJECTIVE

This study examines the association between greater EHR functionality and primary care physician self-reported quality of care.

METHODS

A total of 224 primary care physicians from 38 community health centres (CHCs) in four large Chinese cities participated in a cross-sectional survey to assess CHC care quality. Each CHC director scored their CHC's EHR functionality on the availability of ten typical features covering health information, data, results management, patient access, and clinical decision support. Data analysis utilised hierarchical linear modelling.

RESULTS

The availability of five EHR features was positively associated with physician self-reported clinical quality: share records online with providers outside the practice (β = 0.276, p = 0.04), access records online by the patient (β = 0.325, p = 0.04), alert provider of potential prescription problems (β = 0.353, p = 0.04), send the patient reminders for care (β = 0.419, p = 0.003), and list patients by diagnosis or health risk (β = 0.282, p = 0.04). However, no association was found between specific features availability or total features score and physician self-reported preventive quality.

CONCLUSIONS

This study provides evidence that the availability of EHR systems, and specific features of these systems, was positively associated with physician self-reported quality of care in these 38 CHCs. Future longitudinal studies focused on standardised quality metrics, and designed to control known confounding variables, will further inform quality improvement efforts in primary care.

Symptoms and management of long COVID: A scoping review

AIM

This scoping review aims to describe published work on the symptoms and management of long COVID conditions.

BACKGROUND

Symptoms and management of COVID-19 have focused on the acute stage. However, long-term consequences have also been observed.

METHODS

A scoping review was performed based on the framework suggested by Arksey and O'Malley. We conducted a literature search to retrieve articles published from May 2020 to March 2021 in CINHAL, Cochrane library, Embase, PubMed and Web of science, including backward and forward citation tracking from the included articles. Among the 1880 articles retrieved, 34 articles met our criteria for review: 21 were related to symptom presentation and 13 to the management of long COVID.

RESULTS

Long COVID symptoms were described in 21 articles. Following COVID-19 treatment, hospitalised patients most frequently reported dyspnoea, followed by anosmia/ageusia, fatigue and cough, while non-hospitalised patients commonly reported cough, followed by fever and myalgia/arthralgia. Thirteen studies described management for long COVID: Focused on a multidisciplinary approach in seven articles, pulmonary rehabilitation in three articles, fatigue management in two articles and psychological therapy in one study.

CONCLUSION

People experience varied COVID-19 symptoms after treatment. However, guidelines on evidence-based, multidisciplinary management for long COVID conditions are limited in the literature. The COVID-19 pandemic may extend due to virus mutations; therefore, it is crucial to develop and disseminate evidence-based, multidisciplinary management guidelines.

RELEVANCE TO CLINICAL PRACTICE

A rehabilitation care plan and community healthcare plans are necessary for COVID-19 patients before discharge. Remote programmes could facilitate the monitoring and screening of people with long COVID.

Identifying the Structural and Functional Dimensions of Chronic Disease Follow-Up Interviews

The structure of medical interviews is a topic that has been extensively investigated in the scientific literature. However, some medical contexts remain unexplored, such as follow-up interviews for chronic diseases, despite being particularly rich in interactional, relational and emotional information. In this study, we set out to extract a hierarchical and functional structure from these medical consultations. The analysis method used was inspired by the methods of discourse analysis developed by the Geneva school of Roulet and colleagues. We recorded, transcribed and analyzed 13 authentic chronic disease follow-up interviews with hospital specialists. Following these analyses, we extracted a functional structure of these interviews with the phases and sequences that compose them. Findings distinguish similarities and disparities between chronic disease follow-up visits and other types of medical visits. Our discussion articulates how these types of patient-physician exchanges are similar to, but also different from, other types of medical interactions in different settings.

Care coordination across healthcare systems: development of a research agenda, implications for practice, and recommendations for policy based on a modified Delphi panel

OBJECTIVE

For large, integrated healthcare delivery systems, coordinating patient care across delivery systems with providers external to the system presents challenges. We explored the domains and requirements for care coordination by professionals across healthcare systems and developed an agenda for research, practice and policy.

DESIGN

The modified Delphi approach convened a 2-day stakeholder panel with moderated virtual discussions, preceded and followed by online surveys.

SETTING

The work addresses care coordination across healthcare systems. We introduced common care scenarios and differentiated recommendations for a large (main) healthcare organisation and external healthcare professionals that contribute additional care.

PARTICIPANTS

The panel composition included health service providers, decision makers, patients and care community, and researchers. Discussions were informed by a rapid review of tested approaches to fostering collaboration, facilitating care coordination and improving communication across healthcare systems.

OUTCOME MEASURES

The study planned to formulate a research agenda, implications for practice and recommendations for policy.

RESULTS

For research recommendations, we found consensus for developing measures of shared care, exploring healthcare professionals' needs in different care scenarios and evaluating patient experiences. Agreed practice recommendations included educating external professionals about issues specific to the patients in the main healthcare system, educating professionals within the main healthcare system about the roles and responsibilities of all involved parties, and helping patients better understand the pros and cons of within-system and out-of-system care. Policy recommendations included supporting time for professionals with high overlap in patients to engage regularly and sustaining support for care coordination for high-need patients.

CONCLUSIONS

Recommendations from the stakeholder panel created an agenda to foster further research, practice and policy innovations in cross-system care coordination.

Compliance challenges in a longitudinal COVID-19 cohort using wearables for continuous monitoring

BACKGROUND

Wearables to Investigate the Long Term Cardiovascular and Behavioral Impacts of COVID-19 (WEAICOR) study is a prospective observational study using continuous monitoring to detect and analyze biometrics. Compliance to wearables was a major challenge when conducting the study and was crucial for the results.

OBJECTIVE

The aim of this study is to evaluate patients' compliance to wearable wristbands and determinants of compliance in a prospective COVID-19 cohort.

METHODS

Biostrap wearable device was used to monitor participants' biometric data. Compliance was calculated by dividing the total number of days in which transmissions were sent by the total number of days in the study. Univariate correlation was performed between compliance, days in the study and age, BMI, sex, symptom severity, and number of complications/comorbidites as independent variables. Also, multivariate linear regression was then performed with days in the study as a dependent variable to assess the power of different parameters in determining days in the study.

RESULTS

On hundred twenty-two patients were included in the study. Patients were on average 43 years old and 32% were female. Age was found to be correlated with compliance (r=0.23, P=0.01). In addition, age (r=0.30, P=0.001), BMI (r=0.19, P=0.03) and severity of symptoms (r=0.19, P=0.03) were found to be correlated with days spent in the study. On multivariate analysis with days spent in the study as a dependent variable, only increased age was a significant determinant of compliance with wearables (adjusted R2 = 0.1, β = 1.6, P= 0.01).

CONCLUSIONS

Compliance is a major obstacle in remote monitoring studies and the reasons for a lack thereof are multifactorial. Patient factors such as age, in addition to environmental factors can affect compliance to wearables.

Strengthening the evidence base for mHealth in clinical practice: Conducting research with standalone or interoperable systems - a viewpoint

Objective

The aim of this viewpoint is to inform mobile health (mHealth) evidence development in using standalone or interoperable systems in hospital practice.

Methods

There is a gap between mHealth research and its widespread uptake in clinical practice. Evidence generation is not keeping up with the introduction and implementation of technologies. This is partly a consequence of the technology characteristics and the way research is conducted in a clinical setting. Research and development of mHealth technology can be conducted standalone in a laboratory like setting, standalone in a clinical setting or interoperable with already existing technology in hospital practice.

Results

Standalone systems operate relatively independent from an organizations' existing infrastructure. Using laboratory settings does not reflect the complexity of real-life, but in clinical practice this may be suitable for research assessing usability, feasibility or even clinical and process outcomes at a small scale. Realizing research and development on interoperable mHealth technology solutions, especially with operational EMR systems, is a challenging, time- and resource intensive process and requires large(r) investments, as it is often complicated by a myriad of interfering factors. Interoperable systems are however a more sustainable option in the long run, and generated evidence reflects the real hospital care setting and this option may therefore facilitate dissemination. Choosing either a standalone or interoperable setting affects the research design, the implementation pace and ultimately widespread adoption of the mHealth technology.

Conclusion

We recommend to include these technology characteristics in implementation frameworks and think of evaluation research designs in an early phase.

Electronic health records in Brazil: Prospects and technological challenges

Electronic Health Records (EHR) are critical tools for advancing digital health worldwide. In Brazil, EHR development must follow specific standards, laws, and guidelines that contribute to implementing beneficial resources for population health monitoring. This paper presents an audit of the main approaches used for EHR development in Brazil, thus highlighting prospects, challenges, and existing gaps in the field. We applied a systematic review protocol to search for articles published from 2011 to 2021 in seven databases (Science Direct, Web of Science, PubMed, Springer, IEEE Xplore, ACM Digital Library, and SciELO). Subsequently, we analyzed 14 articles that met the inclusion and quality criteria and answered our research questions. According to this analysis, 78.58% (11) of the articles state that interoperability between systems is essential for improving patient care. Moreover, many resources are being designed and deployed to achieve this communication between EHRs and other healthcare systems in the Brazilian landscape. Besides interoperability, the articles report other considerable elements: (i) the need for increased security with the deployment of permission resources for viewing patient data, (ii) the absence of accurate data for testing EHRs, and (iii) the relevance of defining a methodology for EHR development. Our review provides an overview of EHR development in Brazil and discusses current gaps, innovative approaches, and technological solutions that could potentially address the related challenges. Lastly, our study also addresses primary elements that could contribute to relevant components of EHR development in the context of Brazil's public health system. Systematic review registration: PROSPERO, identifier CRD42021233219, https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021233219.

Effectiveness-implementation hybrid-2 randomised trial of a collaborative Shared Care Model for Detecting Neurodevelopmental Impairments after Critical Illness in Young Children (DAISY): pilot study protocol

INTRODUCTION

In Australia, while paediatric intensive care unit (PICU) mortality has dropped to 2.2%, one in three survivors experience long-term neurodevelopmental impairment, limiting their life-course opportunities. Unlike other high-risk paediatric populations, standardised routine neurodevelopmental follow-up of PICU survivors is rare, and there is limited knowledge regarding the best methods. The present study intends to pilot a combined multidisciplinary, online screening platform and general practitioner (GP) shared care neurodevelopmental follow-up model to determine feasibility of a larger, future study. We will also assess the difference between neurodevelopmental vulnerability and parental stress in two intervention groups and the impact of child, parent, sociodemographic and illness/treatment risk factors on child and parent outcomes.

METHODS AND ANALYSIS

Single-centre randomised effectiveness-implementation (hybrid-2 design) pilot trial for parents of children aged ≥2 months and <4 years discharged from PICU after critical illness or injury. One intervention group will receive 6 months of collaborative shared care follow-up with GPs (supported by online outcome monitoring), and the other will be offered self-directed screening and education about post-intensive care syndrome and child development. Participants will be followed up at 1, 3 and 6 months post-PICU discharge. The primary outcome is feasibility. Secondary outcomes include neurodevelopmental vulnerability and parental stress. An implementation evaluation will analyse barriers to and facilitators of the intervention.

ETHICS AND DISSEMINATION

The study is expected to lead to a full trial, which will provide much-needed guidance about the clinical effectiveness and implementation of follow-up models of care for children after critical illness or injury. The Children's Health Queensland Human Research Ethics Committee approved this study. Dissemination of the outcomes of the study is expected via publication in a peer-reviewed journal, presentation at relevant conferences, and via social media, podcast presentations and open-access medical education resources.

REGISTRATION DETAILS

The trial was prospectively registered with the Australian New Zealand Clinical Trials Registry as 'Pilot testing of a collaborative Shared Care Model for Detecting Neurodevelopmental Impairments after Critical Illness in Young Children' (the DAISY Pilot Study).

TRIAL REGISTRATION NUMBER

ACTRN12621000799853.

Nurses' Experience and Perception of Technology Use in Practice: A Qualitative Study Using an Extended Technology Acceptance Model

The purposes of this study are to provide insight into the factors identified as benefits and drawbacks of technology use by nurses and obtain suggestions on improving technology, based on challenges identified to improve patient outcomes. Holden's extended technology acceptance model was used to describe nurses' perception of technology use in practice. A descriptive design and thematic analysis were used to evaluate participants' logged reflections of their experiences and suggestions for improvements of health information technology. Findings indicate that nurses' experiences and perceptions regarding the use of various types of technology (electronic health records, large databases, crowdsourcing, bio-surveillance) were positive. New subdomains emerged for job performance and efficiency, usefulness for public health, contribution to nursing science, and better communication. Identified challenges were insufficient training and support, lack of interoperability, risk of low-quality care from reliance on technology, increased cost, glitches, and alarm fatigue. Understanding nurses' perceptions of technology is anticipated to enhance care quality and possibly lead to improved outcomes. Nurses' perceptions of the use and acceptance of technology are important as their view is associated with performance and may directly influence clinical outcomes and patient satisfaction. Thematic findings include recommendations from participants to improve patient outcomes and patient care.

Effect of computerised, knowledge-based, clinical decision support systems on patient-reported and clinical outcomes of patients with chronic disease managed in primary care settings: a systematic review

OBJECTIVES

Chronic diseases are the leading cause of disability globally. Most chronic disease management occurs in primary care with outcomes varying across primary care providers. Computerised clinical decision support systems (CDSS) have been shown to positively affect clinician behaviour by improving adherence to clinical guidelines. This study provides a summary of the available evidence on the effect of CDSS embedded in electronic health records on patient-reported and clinical outcomes of adult patients with chronic disease managed in primary care.

DESIGN AND ELIGIBILITY CRITERIA

Systematic review, including randomised controlled trials (RCTs), cluster RCTs, quasi-RCTs, interrupted time series and controlled before-and-after studies, assessing the effect of CDSS (vs usual care) on patient-reported or clinical outcomes of adult patients with selected common chronic diseases (asthma, chronic obstructive pulmonary disease, heart failure, myocardial ischaemia, hypertension, diabetes mellitus, hyperlipidaemia, arthritis and osteoporosis) managed in primary care.

DATA SOURCES

Medline, Embase, CENTRAL, Scopus, Health Management Information Consortium and trial register clinicaltrials.gov were searched from inception to 24 June 2020.

DATA EXTRACTION AND SYNTHESIS

Screening, data extraction and quality assessment were performed by two reviewers independently. The Cochrane risk of bias tool was used for quality appraisal.

RESULTS

From 5430 articles, 8 studies met the inclusion criteria. Studies were heterogeneous in population characteristics, intervention components and outcome measurements and focused on diabetes, asthma, hyperlipidaemia and hypertension. Most outcomes were clinical with one study reporting on patient-reported outcomes. Quality of the evidence was impacted by methodological biases of studies.

CONCLUSIONS

There is inconclusive evidence in support of CDSS. A firm inference on the intervention effect was not possible due to methodological biases and study heterogeneity. Further research is needed to provide evidence on the intervention effect and the interplay between healthcare setting features, CDSS characteristics and implementation processes.

PROSPERO REGISTRATION NUMBER

CRD42020218184.

Effect of Digital Care Platforms on Quality of Care for Oncological Patients and Barriers and Facilitators for Their Implementation: Systematic Review

BACKGROUND

Oncological health care services are challenged by the increasing number of cancer survivors, long-term follow-up care, and fragmentation of care. Digital care platforms are potential tools to deliver affordable, patient-centered oncological care. Previous reviews evaluated only one feature of a digital care platform or did not evaluate the effect on enhancement of information, self-efficacy, continuity of care, or patient- and health care provider-reported experiences. Additionally, they have not focused on the barriers and facilitators for implementation of a digital care platform in oncological care.

OBJECTIVE

The aim of this systematic review was to collect the best available evidence of the effect of a digital care platform on quality of care parameters such as enhancement of available information, self-efficacy, continuity of care, and patient- and health care provider-reported experiences. Additionally, barriers and facilitators for implementation of digital care platforms were analyzed.

METHODS

The PubMed (Medline), Embase, CINAHL, and Cochrane Library databases were searched for the period from January 2000 to May 2020 for studies assessing the effect of a digital care platform on the predefined outcome parameters in oncological patients and studies describing barriers and facilitators for implementation. Synthesis of the results was performed qualitatively. Barriers and facilitators were categorized according to the framework of Grol and Wensing. The Mixed Methods Appraisal Tool was used for critical appraisal of the studies.

RESULTS

Seventeen studies were included for final analysis, comprising 8 clinical studies on the effectiveness of the digital care platform and 13 studies describing barriers and facilitators. Usage of a digital care platform appeared to enhance the availability of information and self-efficacy. There were no data available on the effect of a digital care platform on the continuity of care. However, based on focus group interviews, digital care platforms could potentially improve continuity of care by optimizing the exchange of patient information across institutes. Patient-reported experiences such as satisfaction with the platform were considerably positive. Most barriers for implementation were identified at the professional level, such as the concern for increased workload and unattended release of medical information to patients. Most facilitators were found at the patient and innovation levels, such as improved patient-doctor communication and patient empowerment. There were few barriers and facilitators mentioned at the economic and political levels.

CONCLUSIONS

The use of digital care platforms is associated with better quality of care through enhancement of availability of information and increased self-efficacy for oncological patients. The numerous facilitators identified at the patient level illustrate that patients are positive toward a digital care platform. However, despite these favorable results, robust evidence concerning the effectiveness of digital care platforms, especially from high-quality studies, is still lacking. Future studies should therefore aim to further investigate the effectiveness of digital care platforms, and the barriers and facilitators to their implementation at the economic and political levels.

Supporting breast cancer survivors via text messages: reach, acceptability, and utility of EMPOWER-SMS

Purpose

This study aims to evaluate the reach, usefulness, acceptability, and factors influencing engagement with a lifestyle-focused text message intervention to support women’s mental and physical health after breast cancer treatment.

Methods

This study uses a mixed-methods process evaluation nested in the EMPOWER-SMS randomised controlled trial (n = 160; intervention n = 80, wait-list control n = 80). Data sources included screening logs, text message delivery software analytics, intervention feedback survey, and focus groups (n = 16), which were summarised thematically based on the framework approach.

Results

A total of 387 women met the inclusion criteria (mean_age ± SD = 59.3 ± 11.6 years). Participants who declined (n = 227) were significantly older than those who enrolled (n = 160; 62.2 ± 11.1 vs 55.1 ± 11.1 years, respectively, p < 0.001). Most intervention participants (64/80; 80%) completed the end-of-study survey, reporting the messages were easy to understand (64/64; 100%), useful (58/64; 91%), and motivating (43/64; 67%). The focus groups (n = 16) revealed five factors influencing engagement: (i) feelings of support/continued care, (ii) convenience/flexibility of message delivery, (iii) weblinks, (iv) information from a credible source, and (v) options to save or share messages.

Conclusion

A lifestyle-focused text message program was acceptable and useful for women after breast cancer treatment. However, text messaging may be a barrier for women aged over 68 years. Suggestions for program improvements included delivering the program to patients with other cancers, during all stages of treatment, and including more weblinks in text messages.

Implications for Cancer Survivors

Text message programs offer a low-cost way to deliver post-treatment health support to breast cancer survivors in a non-invasive way. Text messages can improve patient–health professional communication and were found to be acceptable and useful.

The Effect of Telehealth on Hospital Services Use: Systematic Review and Meta-analysis

BACKGROUND

Telehealth interventions, that is, health care provided over a distance using information and communication technology, are suggested as a solution to rising health care costs by reducing hospital service use. However, the extent to which this is possible is unclear.

OBJECTIVE

The aim of this study is to evaluate the effect of telehealth on the use of hospital services, that is, (duration of) hospitalizations, and to compare the effects between telehealth types and health conditions.

METHODS

We searched PubMed, Scopus, and the Cochrane Library from inception until April 2019. Peer-reviewed randomized controlled trials (RCTs) reporting the effect of telehealth interventions on hospital service use compared with usual care were included. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool and quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation guidelines.

RESULTS

We included 127 RCTs in the meta-analysis. Of these RCTs, 82.7% (105/127) had a low risk of bias or some concerns overall. High-quality evidence shows that telehealth reduces the risk of all-cause or condition-related hospitalization by 18 (95% CI 0-30) and 37 (95% CI 20-60) per 1000 patients, respectively. We found high-quality evidence that telehealth leads to reductions in the mean all-cause and condition-related hospitalizations, with 50 and 110 fewer hospitalizations per 1000 patients, respectively. Overall, the all-cause hospital days decreased by 1.07 (95% CI -1.76 to -0.39) days per patient. For hospitalized patients, the mean hospital stay for condition-related hospitalizations decreased by 0.89 (95% CI -1.42 to -0.36) days. The effects were similar between telehealth types and health conditions. A trend was observed for studies with longer follow-up periods yielding larger effects.

CONCLUSIONS

Small to moderate reductions in hospital service use can be achieved using telehealth. It should be noted that, despite the large number of included studies, uncertainties around the magnitude of effects remain, and not all effects are statistically significant.

Digital tools for ambulatory surgery patient surveillance and beyond…

Management of patients in ambulatory (or short stay) surgery relies on optimal organisation of the health care pathways and specific anesthesiology and surgical protocols. Postoperative medico-surgical complications can occur undetected by traditional hospital surveillance. This article identifies modern digital means that can be adapted to surveillance of patients at home: telephone calls or teleconferences, automatic messaging, mobile phone applications, Web platforms and other e-connected devices. For each, we detail their advantages and their limitations.

Effectiveness of a Mobile Health and Self-Management App for High-Risk Patients With Chronic Obstructive Pulmonary Disease in Daily Clinical Practice: Mixed Methods Evaluation Study

BACKGROUND

Mobile health and self-management interventions may positively affect behavioral change and reduce hospital admissions for patients with chronic obstructive pulmonary disease (COPD). However, not all patients qualify for these interventions, and systematic, comprehensive information on implementation- and compliance-related aspects of mobile self-management apps is lacking. Due to the tendency to target digital services to patients in stable phases of disease, it is especially relevant to focus on the use of these services in broad clinical practice for patients recently discharged from hospital.

OBJECTIVE

This study aims to evaluate the effects of a mobile health and self-management app in clinical practice for recently discharged patients with COPD on use of the app, self-management, expectations, and experiences (technology acceptance); patients' and nurses' satisfaction; and hospital readmissions.

METHODS

A prototype of the app was pilot tested with 6 patients with COPD. The COPD app consisted of an 8-week program including the Lung Attack Action Plan, education, medication overview, video consultation, and questionnaires (monitored by nurses). In the feasibility study, adult patients with physician-diagnosed COPD, access to a mobile device, and proficiency of the Dutch language were included from a large teaching hospital during hospital admission. Self-management (Partners in Health Scale), technology acceptance (Unified Theory Acceptance and Use of Technology model), and satisfaction were assessed using questionnaires at baseline, after 8 weeks, and 20 weeks. Use was assessed with log data, and readmission rates were extracted from the electronic medical record.

RESULTS

A total of 39 patients were included; 76.4% (133/174) of patients had to be excluded from participation, and 48.9% of those patients (65/133) were excluded because of lack of digital skills, access to a mobile device, or access to the internet. The COPD app was opened most often in the first week (median 6.0; IQR 3.5-10.0), but its use decreased over time. The self-management element knowledge and coping increased significantly over time (P=.04). The COPD app was rated on a scale of 1-10, with an average score by patients of 7.7 (SD 1.7) and by nurses of 6.3 (SD 1.2). Preliminary evidence about the readmission rate showed that 13% (5/39) of patients were readmitted within 30 days; 31% (12/39) of patients were readmitted within 20 weeks, compared with 14.1% (48/340) and 21.8% (74/340) in a preresearch cohort, respectively.

CONCLUSIONS

The use of a mobile self-management app after hospital discharge seems to be feasible only for a small number of patients with COPD. Patients were satisfied with the service; however, use decreased over time, and only knowledge and coping changed significantly over time. Therefore, future research on digital self-management interventions in clinical practice should focus on including more difficult subgroups of target populations, a multidisciplinary approach, technology-related aspects (such as acceptability), and fine-tuning its adoption in clinical pathways.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04540562; https://clinicaltrials.gov/ct2/show/NCT04540562.

An implementation model for managing cloud-based longitudinal care plans for children with medical complexity

OBJECTIVE

We aimed to iteratively refine an implementation model for managing cloud-based longitudinal care plans (LCPs) for children with medical complexity (CMC).

MATERIALS AND METHODS

We conducted iterative 1-on-1 design sessions with CMC caregivers (ie, parents/legal guardians) and providers between August 2017 and March 2019. During audio-recorded sessions, we asked participants to walk through role-specific scenarios of how they would create, review, and edit an LCP using a cloud-based prototype, which we concurrently developed. Between sessions, we reviewed audio recordings to identify strategies that would mitigate barriers that participants reported relating to 4 processes for managing LCPs: (1) taking ownership, (2) sharing, (3) reviewing, and (4) editing. Analysis informed iterative implementation model revisions.

RESULTS

We conducted 30 design sessions, with 10 caregivers and 20 providers. Participants emphasized that cloud-based LCPs required a team of owners: the caregiver(s), a caregiver-designated clinician, and a care coordinator. Permission settings would need to include universal accessibility for emergency providers, team-level permission options, and some editing restrictions for caregivers. Notifications to review and edit the LCP should be sent to team members before and after clinic visits and after hospital encounters. Mitigating double documentation barriers would require alignment of data fields between the LCP and electronic health record to maximize interoperability.

DISCUSSION

These findings provide a model for how we may leverage emerging Health Insurance Portability and Accountability Act-compliant cloud computing technologies to support families and providers in comanaging health information for CMC.

CONCLUSIONS

Utilizing these management strategies when implementing cloud-based LCPs has the potential to improve team-based care across settings.

What works in managing complex conditions in older people in primary and community care? A state-of-the-art review

The number of older people living with complex health conditions is increasing, with the majority of these managed in primary and community settings. Many models of care have been developed to support them, however, there is mixed evidence on their value and they include multiple overlapping components. We aimed to synthesise the evidence to learn what works for managing complex conditions in older people in primary and community care. We carried out a state-of-the-art review of systematic reviews. We searched three databases (January 2009 to July 2019) for models of primary and community care for long-term conditions, frailty, multimorbidity and complex neurological conditions common to older people such as dementia. We narratively synthesised review findings to summarise the evidence for each model type and identify components which influenced effectiveness. Out of 2,129 unique titles and abstracts, 178 full texts were reviewed and 54 systematic reviews were included. We found that the models of care were more likely to improve depressive symptoms and mental health outcomes than physical health or service use outcomes. Interventions including self-management, patient education, assessment with follow-up care procedures, and structured care processes or pathways had greater evidence of effectiveness. The level of healthcare service integration appeared to be more important than inclusion of specific professional types within a team. However, more experienced and qualified nurses were associated with better outcomes. These conclusions are limited by the overlap between reviews, reliance on vote counting within some included reviews and the quality of study reports. In conclusion, primary and community care interventions for complex conditions in older people should include: (a) clear intervention targets; (b) explicit theoretical underpinnings; and (c) elements of self-management and patient education, structured collaboration between healthcare professionals and professional support. Further work needs to determine the optimal intensity, length, team composition and role of technology in interventions.

Mobile Technology Care Coordination of Long-Term Services and Support: Cluster Randomized Clinical Trial

The purpose of the study was to assess whether the effects of a mobile predictive intervention used by Service Coordinators (SCs) reduce hospital utilization in a Medicaid Long-Term Services and Supports (LTSS) population in Baltimore city during a 5-month intervention. SC participants (n = 11) were recruited to treatment or control groups. LTSS clients (n = 420) followed their SC randomization assignment. Utilization data were obtained from the Maryland Chesapeake Regional Information System for our Patients (CRISP) Health Information Exchange (HIE) system and linked to service coordination records. Study groups were similar in age, gender, race, and years receiving LTSS. SCs' satisfaction with use of the mobile tool was surveyed. SC perceptions were neutral (mean scores ranged from 2.3 to 3.3 on a 5-point scale). No significant differences between groups were observed for all utilization metrics. The mobile technology software system used in this study did not improve health care utilization for a LTSS population needing ongoing clinical and social services coordinated care.

Self-organizing knowledge management might improve the quality of person-centered dementia care: A qualitative study

BACKGROUND

In institutional dementia care, person-centered care improves care processes and the quality of life of residents. However, communication gaps impede the implementation of person-centered care in favor of routinized care.

OBJECTIVE

We evaluated whether self-organizing knowledge management reduces communication gaps and improves the quality of person-centered dementia care.

METHOD

We implemented a self-organizing knowledge management system. Eight significant others of residents with severe dementia and six professional caregivers used a mobile application for six months. We conducted qualitative interviews and focus groups afterward.

MAIN FINDINGS

Participants reported that the system increased the quality of person-centered care, reduced communication gaps, increased the task satisfaction of caregivers and the wellbeing of significant others.

CONCLUSIONS

Based on our findings, we develop the following hypotheses: self-organizing knowledge management might provide a promising tool to improve the quality of person-centered care. It might reduce communication barriers that impede person-centered care. It might allow transferring content-maintaining tasks from caregivers to significant others. Such distribution of tasks, in turn, might be beneficial for both parties. Furthermore, shared knowledge about situational features might guide person-centered interventions.

Evaluating the implementation of a personal health record for chronic primary and secondary care: a mixed methods approach

BACKGROUND

Personal health records (PHRs) provide the opportunity for self-management support, enhancing communication between patients and caregivers, and maintaining and/or improving the quality of chronic disease management. Their implementation is a multi-level and complex process, requiring a holistic approach that takes into account the technology, its users and the context of implementation. The aim of this research is to evaluate the fidelity of a PHR in chronic care (the degree to which it was implemented as intended) in order to explain the found effects.

METHODS

A convergent parallel mixed methods design was used, where qualitative and quantitative data were collected in parallel, analyzed separately, and finally merged. Log data of 536 users were used to gain insight into the actual long-term use of the PHR (the dose). Focus group meetings among caregivers (n = 13) were conducted to assess program differentiation (or intended use). Interviews with caregivers (n = 28) and usability tests with potential end-users (n = 13) of the PHR were used to understand the responsiveness and the differences and similarities between the intended and actual use of the PHR.

RESULTS

The results of the focus groups showed that services for coaching are strongly associated with monitoring health values and education. However, the PHR was not used that way during the study period. In the interviews, caregivers indicated that they were ignorant on how to deploy the PHR in current working routines. Therefore, they find it difficult to motivate their patients in using the PHR. Participants in the usability study indicate that they would value a PHR in the future, given that the usability will be improved and that the caregivers will use it in daily practice as well.

CONCLUSIONS

In this study, actual use of the PHRs by patients was influenced by the responsiveness of caregivers. This responsiveness is likely to be strongly influenced by the perceived support when defining the differentiation and delivery of the PHR. A mixed-methods approach to understand intervention fidelity was of added value in providing explanations for the found effects that could not be revealed by solely focusing on the effectiveness of the technology in an experimental trial.

Artificial intelligence supported patient self-care in chronic heart failure: a paradigm shift from reactive to predictive, preventive and personalised care

Heart failure (HF) is one of the most complex chronic disorders with high prevalence, mainly due to the ageing population and better treatment of underlying diseases. Prevalence will continue to rise and is estimated to reach 3% of the population in Western countries by 2025. It is the most important cause of hospitalisation in subjects aged 65 years or more, resulting in high costs and major social impact. The current “one-size-fits-all” approach in the treatment of HF does not result in best outcome for all patients. These facts are an imminent threat to good quality management of patients with HF. An unorthodox approach from a new vision on care is required. We propose a novel predictive, preventive and personalised medicine approach where patients are truly leading their management, supported by an easily accessible online application that takes advantage of artificial intelligence. This strategy paper describes the needs in HF care, the needed paradigm shift and the elements that are required to achieve this shift. Through the inspiring collaboration of clinical and high-tech partners from North-West Europe combining state of the art HF care, artificial intelligence, serious gaming and patient coaching, a virtual doctor is being created. The results are expected to advance and personalise self-care, where standard care tasks are performed by the patients themselves, in principle without involvement of healthcare professionals, the latter being able to focus on complex conditions. This new vision on care will significantly reduce costs per patient while improving outcomes to enable long-term sustainability of top-level HF care.

Enhanced Self-Efficacy and Behavioral Changes Among Patients With Diabetes: Cloud-Based Mobile Health Platform and Mobile App Service

Background

The prevalence of chronic disease is increasing rapidly. Health promotion models have shifted toward patient-centered care and self-efficacy. Devices and mobile app in the Internet of Things (IoT) have become critical self-management tools for collecting and analyzing personal data to improve individual health outcomes. However, the precise effects of Web-based interventions on self-efficacy and the related motivation factors behind individuals’ behavioral changes have not been determined.

Objective

The objective of this study was to gain insight into patients' self-efficacy with newly diagnosed diabetes (type 2 diabetes mellitus) and analyze the association of patient-centered health promotion behavior and to examine the implications of the results for IoT and mobile health mobile app features.

Methods

The study used data from the electronic health database (n=3128). An experimental design (n=121) and randomized controlled trials were employed to determine patient preferences in the health promotion program (n=62) and mobile self-management education (n=28). The transtheoretical model was used as a framework for observing self-management behavior for the improvement of individual health, and the theory of planned behavior was used to evaluate personal goals, execution, outcome, and personal preferences. A mobile app was used to determine individualized health promotion interventions and to apply these interventions to improve patients’ self-management and self-efficacy.

Results

Mobile questionnaires were administered for pre- and postintervention assessment through mobile app. A dynamic questionnaire allocation method was used to follow up and monitor patient behavioral changes in the subsequent 6 to 18 months. Participants at a high risk of problems related to blood pressure (systolic blood pressure ≥120 mm Hg) and body mass index (≥23 kg/m²) indicated high motivation to change and to achieve high scores in the self-care knowledge assessment (n=49, 95% CI −0.26% to −0.24%, P=.052). The associated clinical outcomes in the case group with the mobile-based intervention were slightly better than in the control group (glycated hemoglobin mean −1.25%, 95% CI 6.36 to 7.47, P=.002). In addition, 86% (42/49) of the participants improved their health knowledge through the mobile-based app and information and communications technology. The behavior-change compliance rate was higher among the women than among the men. In addition, the personal characteristics of steadiness and dominance corresponded with a higher compliance rate in the dietary and wellness intervention (83%, 81/98). Most participants (71%, 70/98) also increased their attention to healthy eating, being active, and monitoring their condition (30% 21/70, 21% 15/70, and 20% 14/70, respectively).

Conclusions

The overall compliance rate was discovered to be higher after the mobile app–based health intervention. Various intervention strategies based on patient characteristics, health care–related word-of-mouth communication, and social media may be used to increase self-efficacy and improve clinical outcomes. Additional research should be conducted to determine the most influential factors and the most effective adherence management techniques.

Requirements for implementing online information material for patients with low back pain in general practice: an interview study

OBJECTIVE

To identify general practitioners' (GPs) barriers and facilitators regarding the use of health information technology (HIT) in the treatment of patients with low back pain (LBP).

DESIGN

A qualitative study employing a participatory design approach, with an inductive analytical thematic approach utilising semi-structured interviews. Empirical data was analysed using the qualitative data analysis software (QDAS) Nvivo.

SETTING

General practices in Denmark.

SUBJECTS

Eight interviews were conducted with an average duration of 60 min. The interviewees were GPs from different geographical settings and different organisational structures, varying in age and professional interests.

MAIN OUTCOME MEASURES

Barriers and facilitators for future use of the HIT application for patients with LBP.

RESULTS

Through the inclusion of healthcare professionals in the design process, this study found that in order for GPs to recommend a HIT application it is essential to target the application towards their patients. Furthermore, GPs required that the HIT application should support patient self-management. Additionally, the content of the HIT application should support the initiated treatment and it should be easy for GPs to recommend the HIT application. Finally, healthcare professionals need to be involved in the design process.

CONCLUSION

When designing health IT applications for patients with LBP in general practice it is important to include both patients and GPs in the design process. GPs would be more willing to recommend a HIT application that: applies content in line with frequently used recommendations; targets patients; supports patients' self-management; and supports the patients' needs. KEY POINTS Online information is currently applied in general practice to some patients with low back pain Online information cannot replace the GP, but can rather be a bonding tool between the patient and the GP It is important to address both GP and patient barriers to applying new technology and to consider the literacy level Participatory methods could play a central role in the future development of online information material.

Design and Development of a Person-Centered Patient Portal Using Participatory Stakeholder Co-Design

Background

Patient portals are increasingly accepted as part of standard medical care. However, to date, most patient portals provide just passive access to medical data. The use of modern technology such as smartphones and data personalization algorithms offers the potential to make patient portals more person-centered and enabling.

Objective

The aim of this study is to share our experience in designing and developing a person-centered patient portal following a participatory stakeholder co-design approach.

Methods

Our stakeholder co-design approach comprised 6 core elements: (1) equal coleadership, including a cancer patient on treatment; (2) patient preference determination; (3) security, governance, and legal input; (4) continuous user evaluation and feedback; (5) continuous staff input; and (6) end-user testing. We incorporated person-centeredness by recognizing that patients should decide for themselves their level of medical data access, all medical data should be contextualized with explanatory content, and patient educational material should be personalized and timely.

Results

Using stakeholder co-design, we built, and are currently pilot-testing, a person-centered patient portal smartphone app called Opal.

Conclusions

Inclusion of all stakeholders in the design and development of patient-facing software can help ensure that the necessary elements of person-centeredness, clinician acceptability, and informatics feasibility are achieved.

Barriers and Facilitators Affecting Patient Portal Implementation from an Organizational Perspective: Qualitative Study

Background

The number of patient portals is rising, and although portals can have positive effects, their implementation has major impacts on the providing health care institutions. However, little is known about the organizational factors affecting successful implementation. Knowledge of the specific barriers to and facilitators of various stakeholders is likely to be useful for future implementations.

Objective

The objective of this study was to identify the barriers to and facilitators of patient portal implementation facing various stakeholders within hospital organizations in the Netherlands.

Methods

Purposive sampling was used to select hospitals of various types. A total of 2 university medical centers, 3 teaching hospitals, and 2 general hospitals were included. For each, 3 stakeholders were interviewed: (1) medical professionals, (2) managers, and (3) information technology employees. In total, 21 semistructured interviews were conducted using the Grol and Wensing model, which describes barriers to and facilitators of change in health care practice at 6 levels: (1) innovation; (2) individual professional; (3) patient; (4) social context; (5) organizational context; and (6) economic and political context. Two researchers independently selected and coded quotes by applying this model using a (deductive) directed content approach. Additional factors related to technical and portal characteristics were added using the model of McGinn et al, developed for implementation of electronic health records.

Results

In total, we identified 376 quotes, 26 barriers, and 28 facilitators. Thirteen barriers and 12 facilitators were common for all stakeholder groups. The facilitators’ perceived usefulness (especially less paperwork) was mentioned by all the stakeholders, followed by subjects’ positive attitude. The main barriers were lack of resources (namely, lack of staff and materials), financial difficulties (especially complying with high costs, lack of reimbursements), and guaranteeing privacy and security (eg, strict regulations). Both similarities and differences were found between stakeholder groups and hospital types. For example, managers and information technology employees mainly considered guaranteeing privacy and security as a predominant barrier. Financial difficulties were particularly mentioned by medical professionals and managers.

Conclusions

Patient portal implementation is a complex process and is not only a technical process but also affects the organization and its staff. Barriers and facilitators occurred at various levels and differed among hospital types (eg, lack of accessibility) and stakeholder groups (eg, sufficient resources) in terms of several factors. Our findings underscore the importance of involving multiple stakeholders in portal implementations. We identified a set of barriers and facilitators that are likely to be useful in making strategic and efficient implementation plans.

Clarifying the Concept of Adherence to eHealth Technology: Systematic Review on When Usage Becomes Adherence

BACKGROUND

In electronic health (eHealth) evaluations, there is increasing attention for studying the actual usage of a technology in relation to the outcomes found, often by studying the adherence to the technology. On the basis of the definition of adherence, we suggest that the following three elements are necessary to determine adherence to eHealth technology: (1) the ability to measure the usage behavior of individuals; (2) an operationalization of intended use; and (3) an empirical, theoretical, or rational justification of the intended use. However, to date, little is known on how to operationalize the intended usage of and the adherence to different types of eHealth technology.

OBJECTIVE

The study aimed to improve eHealth evaluations by gaining insight into when, how, and by whom the concept of adherence has been used in previous eHealth evaluations and finding a concise way to operationalize adherence to and intended use of different eHealth technologies.

METHODS

A systematic review of eHealth evaluations was conducted to gain insight into how the use of the technology was measured, how adherence to different types of technologies was operationalized, and if and how the intended use of the technology was justified. Differences in variables between the use of the technology and the operationalization of adherence were calculated using a chi-square test of independence.

RESULTS

In total, 62 studies were included in this review. In 34 studies, adherence was operationalized as "the more use, the better," whereas 28 studies described a threshold for intended use of the technology as well. Out of these 28, only 6 reported a justification for the intended use. The proportion of evaluations of mental health technologies reporting a justified operationalization of intended use is lagging behind compared with evaluations of lifestyle and chronic care technologies. The results indicated that a justification of intended use does not require extra measurements to determine adherence to the technology.

CONCLUSIONS

The results of this review showed that to date, justifications for intended use are often missing in evaluations of adherence. Evidently, it is not always possible to estimate the intended use of a technology. However, such measures do not meet the definition of adherence and should therefore be referred to as the actual usage of the technology. Therefore, it can be concluded that adherence to eHealth technology is an underdeveloped and often improperly used concept in the existing body of literature. When defining the intended use of a technology and selecting valid measures for adherence, the goal or the assumed working mechanisms should be leading. Adherence can then be standardized, which will improve the comparison of adherence rates to different technologies with the same goal and will provide insight into how adherence to different elements contributed to the outcomes.