Core Components for a Clinically Integrated mHealth App for Asthma Symptom Monitoring

Community engagement in the development of health-related data visualizations: a scoping review

OBJECTIVE

This scoping review aims to address a gap in the literature on community engagement in developing data visualizations intended to improve population health. The review objectives are to: (1) synthesize literature on the types of community engagement activities conducted by researchers working with community partners and (2) characterize instances of "creative data literacy" within data visualizations developed in community-researcher partnerships.

METHODS

Using the 2018 PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines, the review focuses on peer-reviewed journal articles from 2010 to 2022 in PubMed, Web of Science, and Google Scholar. A community engagement tool was applied to the studies by independent reviewers to classify levels of community engagement, social determinants, and vulnerable populations.

RESULTS

Twenty-seven articles were included in the scoping review. Twelve articles worked with vulnerable populations. Four articles attempted to alleviate barriers to representation in their respective studies, with addressing language barriers being the most prevalent approach. Thirteen articles considered social determinants of health. Sixteen studies engaged in iterative approaches with intended users when developing the visualization or tool.

DISCUSSION

Only a few significant examples of creative data literacy are incorporated in the studies. We recommend a specific focus on engaging intended users at every step of the development process, addressing language and cultural differences, and empowering intended users as data storytellers.

CONCLUSIONS

There is room for deeper and more meaningful community involvement in the development of health-related data visualizations geared towards them.

Are older adults considered in asthma and chronic obstructive pulmonary disease mobile health research? A scoping review

BACKGROUND

The use of mobile health (mHealth) for asthma and chronic obstructive pulmonary disease (COPD) is rapidly growing and may help address the complex respiratory care needs of our ageing population. However, little is currently known about how airways mHealth is developed and used among older adults (≥65 years).

OBJECTIVE

To identify if and how older adults with asthma and COPD have been incorporated across the mHealth research cycle.

METHODS

We searched Ovid MEDLINE, EMBASE, CINAHL and the Cochrane Central Registry of Controlled Trials for studies pertaining to the development or evaluation of asthma and COPD mHealth for adults published after 2010. Study, participant and mHealth details, including any considerations of older age, were extracted, synthesised and charted.

RESULTS

A total of 334 studies of 191 mHealth tools were identified. Adults ≥65 years old were included in 33.3% of asthma mHealth studies and 85.3% of COPD studies. Discussions of older age focused on barriers to technology use. Methodologic and/or analytic considerations of older age were mostly absent throughout the research cycle. Among the 28 instances quantitative age-related analyses were detailed, 12 described positive mHealth use and satisfaction outcomes in older adults versus negative or equivocal outcomes.

CONCLUSION

We identified an overall lack of consideration for older age throughout the airways mHealth research cycle, even among COPD mHealth studies that predominantly included older adults. We also found a contrast between the perceptions of how older age might negatively influence mHealth use and available quantitative evaluations. Future airways mHealth research must better integrate the needs and concerns of older adults.

Design and development of an eHealth intervention to support self-management in people with musculoskeletal disorders - 'eHealth: It's TIME': a study protocol

Background: Musculoskeletal disorders (MSDs) are a leading cause of global morbidity, with the burden expected to increase in the near future. Self-management, with the support of healthcare professionals, is recommended for many MSDs. However, frequent clinical contact is not feasible. Previous research has highlighted the need for a co-designed eHealth-mediated self-management follow-up support intervention which integrates remote monitoring and behavioural change. Thus, the current study aims to develop and design a user-centred, eHealth-mediated self-management support prototype for people with MSDs. Methods: A three-step, iterative system development cycle will be utilised to develop and design the "eHealth: It's TIME prototype". The three-step process will include creating website features and content using two sequential focus groups with people with MSDs (n = 6 - 8); heuristic testing using the 10 heuristic principles of Nielsen (n = 5); and usability testing through in-person 60-minute interviews with people with MSDs (n = 3 - 5) and musculoskeletal physiotherapists (n = 3 - 5). Conclusion: The eHealth: It's TIME prototype will be a systematically developed, follow-up self-management support intervention guided by behavioural change theory and the preferences of end users.

Integrating a Patient Engagement App into an Electronic Health Record-Enabled Workflow Using Interoperability Standards

BACKGROUND

Patient use of mobile health applications is increasing. To promote patient-centered care, data from these apps must be integrated into clinician workflows within the electronic health record (EHR). Health Level 7 Fast Healthcare Interoperability Resources (FHIR) offers a standards-based application programming interface (API) that may support such integration.

OBJECTIVE

We aimed to use interoperability standards to integrate a patient mobile application (coronavirus 2019 [COVID-19] Tracker) with an EHR. The COVID-19 Tracker engages patients by sending introductory and reminder text messages, collecting vital signs and symptom data from COVID-19 patients, and providing actionable guidance if concerning issues are identified. This case report explored the use of FHIR APIs to integrate the app into EHR-enabled clinical workflows.

METHODS

The authors used notes from project meetings and from semistructured discussions among the application development team to track the design and implementation processes. Seven points of integration between the application and the EHR were identified, and approaches using FHIR to perform these integrations were delineated.

RESULTS

Although this clinical decision support integration project benefited from its standards-based approach, many challenges were encountered. These were due to (1) partial implementation of the FHIR standard in the EHR, particularly, components needed for patient engagement applications; (2) limited experience with the adoption of FHIR standards; and (3) gaps in the current FHIR standard. Alternative approaches, often not based on interoperability standards, were developed to overcome these limitations.

CONCLUSION

Despite the challenges encountered due to the early stages of FHIR development and adoption, FHIR standards provide a promising mechanism for overcoming longstanding barriers and facilitating the integration of patient engagement apps with EHRs. To accelerate the integration of apps into clinical workflows, additional components of the FHIR standard must be implemented within the EHR and other clinical systems. Continued expansion of available FHIR resources will help with tighter workflow integration.

Development and Testing of an Electronic Health Record‐Integrated Patient‐Reported Outcome Application and Intervention to Improve Efficiency of Rheumatoid Arthritis Care

Objective

Many patients with rheumatoid arthritis (RA) have difficulty finding clinicians to treat them because of workforce shortages. We developed an app to address this problem by improving care efficiency. The app collects patient‐reported outcomes (PROs) and can be used to inform visit timing, potentially reducing the volume of low‐value visits. We describe the development process, intervention design, and planned study for testing the app.

Methods

We employed user‐centered design, interviewing patients and clinicians, to develop the app. To improve visit efficiency, symptom tracking logic alerts clinicians to PRO trends: worsening PROs generate alerts suggesting an earlier visit, and stable or improving PROs generate notifications that scheduled visits could be delayed. An interrupted time‐series analysis with a nonrandomized control population will allow assessment of the impact of the app on visit frequency.

Results

Patient interviews identified several of the following needs for effective app and intervention design: the importance of a simple user interface facilitating rapid answering of PROs, the availability of condensed summary information with links to more in‐depth answers to common questions regarding RA, and the need for clinicians to discuss the PRO data during visits with patients. Clinician interviews identified the following user needs: PRO data must be easy to view and use during the clinical workflow, and there should be reduced interval visits when PROs are trending worse. Some clinicians believed visits could be delayed for patients with stable PROs, whereas others raised concerns.

Conclusion

PRO apps may improve care efficiency in rheumatology. Formal evaluation of an integrated PRO RA app is forthcoming.

Hurdles to developing and scaling remote patients' health management tools and systems: a scoping review

BACKGROUND

Despite all the excitement and hype generated regarding the expected transformative impact of digital technology on the healthcare industry, traditional healthcare systems around the world have largely remained unchanged and resultant improvements in developed countries are slower than anticipated. One area which was expected to significantly improve the quality of and access to primary healthcare services in particular is remote patient monitoring and management. Based on a combination of rapid advances in body sensors and information and communication technologies (ICT), it was hoped that remote patient management tools and systems (RPMTSs) would significantly reduce the care burden on traditional healthcare systems as well as health-related costs. However, the uptake or adoption of above systems has been extremely slow and their roll out has not yet properly taken off especially in developing countries where they ought to have made the greatest positive impact.

AIM

The aim of the study was to assess whether or not recent, relevant literature would support the development of in-community, design, deployment and implementation framework based on three factors thought to be important drivers and levers of RPMTS's adoption and scalability.

METHODS

A rapid, scoping review conducted on relevant articles obtained from PubMed, MEDLINE, PMC and Cochrane databases and grey literature on Google and published between 2012 and May 2020, by combining a number of relevant search terms and phrases.

RESULTS

Most RPMTSs are targeted at and focused on a single disease, do not extensively involve patients and clinicians in their early planning and design phases, are not designed to best serve a specific catchment area and are mainly directed at post-hospital, disease management settings. This may be leading to a situation where patients, potential patients and clinicians simply do not make use of these tools, leading to low adoption and scalability thereof.

CONCLUSION

The development of a user-centred, context-dependent, customizable design and deployment framework could potentially increase the adoption and scalability of RPMTSs, if such framework addressed a combination of diseases, prevalent in a given specific catchment area, especially in developing countries with limited financial resources.

Toward an asthma patient-reported outcome measure for use in digital remote monitoring

OBJECTIVE

To develop and test a patient-reported outcome measure (PROM) for suitability in digital remote asthma symptom monitoring to identify uncontrolled asthma.

METHODS

We modified a 5-item PROM that does not require a license, the asthma control measure (ACM), from a one-month to one-week lookback period, and evaluated it using the 5-item asthma control questionnaire (ACQ-5). We recruited subjects with asthma through MTurk, an online platform.

RESULTS

In a sample of 498 subjects, the ACM identified uncontrolled asthma with sensitivity 0.99 and specificity 0.65. The two measures correlated with r = 0.81.

CONCLUSION

The ACM modified to a weekly lookback period can differentiate patients with well-controlled asthma from those with uncontrolled asthma. This PROM does not require a license and can be used in digital remote monitoring interventions.

Development of a Digital Health Intervention for Rheumatoid Arthritis Symptom Management in a Biotechnology Industry Context: Protocol for the Application of a Human-Centered Design Framework

Background

Involving chronically ill patients in the management of their health is widely recognized as a vital component of high-quality health care. However, to assume the role of informed participants, patients need both access to their health information and assistance in interpreting such data. Smartphone technology with SMS text messaging functionality offers a convenient and minimally demanding mechanism for providing such dual capabilities to patients. To date, a number of similar digital tools have been developed for use in various chronic and progressive disease conditions, including rheumatoid arthritis.

Objective

This paper aims to describe the development of a research protocol that applies a human-centered design (HCD) approach to develop a mobile health (mHealth) intervention to support symptom management and treatment adherence for rheumatoid arthritis.

Methods

To guide the development of the mHealth intervention for use within a commercial biotechnology context, we selected and applied an HCD framework consisting of three phases: understanding, ideation, and implementation.

Results

Leveraging the framework, we mapped the key objectives and research questions to each phase and identified the HCD techniques and methods most suitable for addressing them. In addition, we identified the need to include a fourth phase, one that referred to postimplementation assessment, which would enable evaluation of patient engagement and intervention impact on symptom self-management.

Conclusions

This paper presents a research protocol that applied an HCD framework to guide the development of an mHealth intervention within a commercial biotechnology context. This type of guidance is salient because commercial entities are becoming one of the leading producers of this type of intervention. However, the methodologies used and challenges faced from a research and development perspective are not well-represented in the published research literature to date. Our application of the HCD framework yielded important findings. Each phase of the HCD framework provided important guidance for increasing the likelihood that the final product would be understandable, acceptable, feasible, and engaging to use. Consistent with other researchers in the field of mHealth interventions, we identified the need to add a fourth phase to the HCD framework, one that focused on a postimplementation assessment to guide further improvements to support adoption in real-world settings.

International Registered Report Identifier (IRRID)

RR1-10.2196/16430

Electronic Medical Records for (Visceral) Medicine: An Overview of the Current Status and Prospects

Background

Electronic medical records (EMRs) offer key advantages over analog documentation in healthcare. In addition to providing details about current and past treatments, EMRs enable clear and traceable documentation regardless of the location. This supports evidence-based, multi-professional treatment and leads to more efficient healthcare. However, there are still several challenges regarding the use of EMRs. Understanding these challenges is essential to improve healthcare. The aim of this article is to provide an overview of the current state of EMRs in the field of visceral medicine, to describe the future prospects in this field, and to highlight some of the challenges that need to be faced.

Summary

The benefits of EMRs are manifold and particularly pronounced in the area of quality assurance and improvement of communication not only between different healthcare professionals but also between physicians and patients. Besides the danger of medical errors, the health consequences for the users (cognitive load) arise from poor usability or a system that does not fit into the real world. Involving users in the development of EMRs in the sense of participatory design can be helpful here. The use of EMRs in practice together with patients should be accompanied by training to ensure optimal outcomes in terms of shared decision-making.

Key Message

EMRs offer a variety of benefits. However, it is critical to consider user involvement, setting specificity, and user training during development, implementation, and use in order to minimize unintended consequences.

User-centered design of a scalable, electronic health record-integrated remote symptom monitoring intervention for patients with asthma and providers in primary care

OBJECTIVE

To determine user and electronic health records (EHR) integration requirements for a scalable remote symptom monitoring intervention for asthma patients and their providers.

METHODS

Guided by the Non-Adoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework, we conducted a user-centered design process involving English- and Spanish-speaking patients and providers affiliated with an academic medical center. We conducted a secondary analysis of interview transcripts from our prior study, new design sessions with patients and primary care providers (PCPs), and a survey of PCPs. We determined EHR integration requirements as part of the asthma app design and development process.

RESULTS

Analysis of 26 transcripts (21 patients, 5 providers) from the prior study, 21 new design sessions (15 patients, 6 providers), and survey responses from 55 PCPs (71% of 78) identified requirements. Patient-facing requirements included: 1- or 5-item symptom questionnaires each week, depending on asthma control; option to request a callback; ability to enter notes, triggers, and peak flows; and tips pushed via the app prior to a clinic visit. PCP-facing requirements included a clinician-facing dashboard accessible from the EHR and an EHR inbox message preceding the visit. PCP preferences diverged regarding graphical presentations of patient-reported outcomes (PROs). Nurse-facing requirements included callback requests sent as an EHR inbox message. Requirements were consistent for English- and Spanish-speaking patients. EHR integration required use of custom application programming interfaces (APIs).

CONCLUSION

Using the NASSS framework to guide our user-centered design process, we identified patient and provider requirements for scaling an EHR-integrated remote symptom monitoring intervention in primary care. These requirements met the needs of patients and providers. Additional standards for PRO displays and EHR inbox APIs are needed to facilitate spread.

Provider Preferences for Patient-Generated Health Data Displays in Pediatric Asthma: A Participatory Design Approach

Objective  There is a lack of evidence on how to best integrate patient-generated health data (PGHD) into electronic health record (EHR) systems in a way that supports provider needs, preferences, and workflows. The purpose of this study was to investigate provider preferences for the graphical display of pediatric asthma PGHD to support decisions and information needs in the outpatient setting.

Methods  In December 2019, we conducted a formative evaluation of information display prototypes using an iterative, participatory design process. Using multiple types of PGHD, we created two case-based vignettes for pediatric asthma and designed accompanying displays to support treatment decisions. Semi-structured interviews and questionnaires with six participants were used to evaluate the display usability and determine provider preferences.

Results  We identified provider preferences for display features, such as the use of color to indicate different levels of abnormality, the use of patterns to trend PGHD over time, and the display of environmental data. Preferences for display content included the amount of information and the relationship between data elements.

Conclusion  Overall, provider preferences for PGHD include a desire for greater detail, additional sources, and visual integration with relevant EHR data. In the design of PGHD displays, it appears that the visual synthesis of multiple PGHD elements facilitates the interpretation of the PGHD. Clinicians likely need more information to make treatment decisions when PGHD displays are introduced into practice. Future work should include the development of interactive interface displays with full integration of PGHD into EHR systems.

Patient-Generated Health Data in Pediatric Asthma: Exploratory Study of Providers' Information Needs

BACKGROUND

Adolescents are using mobile health apps as a form of self-management to collect data on symptoms, medication adherence, and activity. Adding functionality to an electronic health record (EHR) to accommodate disease-specific patient-generated health data (PGHD) may support clinical care. However, little is known on how to incorporate PGHD in a way that informs care for patients. Pediatric asthma, a prevalent health issue in the United States with 6 million children diagnosed, serves as an exemplar condition to examine information needs related to PGHD.

OBJECTIVE

In this study we aimed to identify and prioritize asthma care tasks and decisions based on pediatric asthma guidelines and identify types of PGHD that might support the activities associated with the decisions. The purpose of this work is to provide guidance to mobile health app developers and EHR integration.

METHODS

We searched the literature for exemplar asthma mobile apps and examined the types of PGHD collected. We identified the information needs associated with each decision in accordance with consensus-based guidelines, assessed the suitability of PGHD to meet those needs, and validated our findings with expert asthma providers.

RESULTS

We mapped guideline-derived information needs to potential PGHD types and found PGHD that may be useful in meeting information needs. Information needs included types of symptoms, symptom triggers, medication adherence, and inhaler technique. Examples of suitable types of PGHD were Asthma Control Test calculations, exposures, and inhaler use. Providers suggested uncontrolled asthma as a place to focus PGHD efforts, indicating that they preferred to review PGHD at the time of the visit.

CONCLUSIONS

We identified a manageable list of information requirements derived from clinical guidelines that can be used to guide the design and integration of PGHD into EHRs to support pediatric asthma management and advance mobile health app development. Mobile health app developers should examine PGHD information needs to inform EHR integration efforts.

Smartphone App for monitoring Asthma in children and adolescents

PURPOSE

The asthma stepwise treatment approach recommended is based on monitoring patients' symptoms. The Asthma Research in Children and Adolescents (ARCA) cohort was created to provide evidence about the evolution of persistent asthma. This manuscript describes the development of an electronic health tool, comprising a mobile health application for patients with asthma and its associated online platform for pediatricians to monitor them.

METHODS

The development process followed 7 phases: the first 5 (Conceptualization, Preparation, Assessment scheduling, Image and user interface, and Technical development) defined and designed the tool, followed by a testing phase (functionality assessment and pilot test with ARCA patients), and a last phase which evaluated usability. Since the target population was aged 6-16 years, three versions were designed within the same smartphone application: parents/proxy, children, and adolescents. The online platform for pediatricians provides real-time information from the application: patients' responses over time with color-coded charts (red/amber/green, as in traffic lights).

RESULTS

The pilot test through semi-structured phone interviews of the first 50 participants included in the ARCA study (n = 53) detected their misunderstandings. Pediatricians were trained to emphasize that the application is free of charge and requires monthly answers. Median of the System Usability Scale scores (n = 85), ranging 0 (negative)-100 (positive), was > 93 in the three age versions of the application.

CONCLUSIONS

Technology has the capability of transforming the use of patient-reported outcomes. Describing all the development phases of a mobile health application for monitoring children and adolescents with asthma may increase the knowledge on how to design applications for young patients.

Design thinking as an approach for innovation in healthcare: systematic review and research avenues

Design thinking has been increasingly adopted as an approach to support innovation in healthcare. Recent publications report design thinking application to various innovation projects, across medical specialties, including paediatrics, psychiatry, radiology, gastroenterology, oncology, orthopaedics and surgery, as well as to innovation in hospital operations and healthcare management. Current literature in the area typically focuses on single case descriptions. With the recent increase in the number of cases, there is an opportunity to assess multiple cases to identify patterns and avenues for further research. This study provides a systematic review of published design thinking projects in healthcare. The aim of the study is to provide an overview of how design thinking has been applied in the healthcare sector. Data collection was based on Institute of Scientific Information (ISI) Web of Science, PubMed and Scopus databases. The systematic review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 32 original pieces of research was selected for analysis, being classified and assessed. The paper presents current status of research and practice from various perspectives, including the design thinking progression phase—inspiration, ideation, implementation—and the prevalence of design thinking tools. Avenues for further research include the need to increase focus on the inspiration phase, the opportunity for platforms for leveraging the integration of individuals in innovation projects, and the opportunity to enhance the role of lead users in healthcare innovation.

Evaluating Asthma Mobile Apps to Improve Asthma Self-Management: User Ratings and Sentiment Analysis of Publicly Available Apps

BACKGROUND

The development and use of mobile health (mHealth) apps for asthma management have risen dramatically over the past two decades. Asthma apps vary widely in their content and features; however, prior research has rarely examined preferences of users of publicly available apps.

OBJECTIVE

The goals of this study were to provide a descriptive overview of asthma mobile apps that are publicly available and to assess the usability of asthma apps currently available on the market to identify content and features of apps associated with positive and negative user ratings.

METHODS

Reviews were collected on June 23, 2020, and included publicly posted reviews until June 21, 2020. To characterize features associated with high or low app ratings, we first dichotomized the average user rating of the asthma app into 2 categories: a high average rating and a low average rating. Asthma apps with average ratings of 4 and above were categorized as having a high average rating. Asthma apps with average ratings of less than 4 were categorized as having a low average rating. For the sentiment analysis, we modeled both 2-word (bi-gram) and 3-word (tri-gram) phrases which commonly appeared across highly rated and lowly rated apps.

RESULTS

Of the 10 apps that met the inclusion criteria, a total of 373 reviews were examined across all apps. Among apps reviewed, 53.4% (199/373) received high ratings (average ratings of 4 or 5) and 47.2% (176/373) received low ratings (average ratings of 3 or less). The number of ratings across all apps ranged from 188 (AsthmaMD) to 10 (My Asthma App); 30% (3/10) of apps were available on both Android and iOS. From the sentiment analysis, key features of asthma management that were common among highly rated apps included the tracking of peak flow readings (n=48), asthma symptom monitoring (n=11), and action plans (n=10). Key features related to functionality that were common among highly rated apps included ease of use (n=5). Users most commonly reported loss of data (n=14) and crashing of app (n=12) as functionality issues among poorly rated asthma apps.

CONCLUSIONS

Our study results demonstrate that asthma app quality, maintenance, and updates vary widely across apps and platforms. These findings may call into question the long-term engagement with asthma apps, a crucial factor for determining their potential to improve asthma self-management and asthma clinical outcomes.

Mobile Health and Inhaler-Based Monitoring Devices for Asthma Management

Mobile health and web applications (apps), wearables, and other personal monitoring devices have tremendous potential to improve the management of asthma. More than 500 asthma-related apps, whether standalone or paired with sensors on inhalers, are currently available for health education, symptom recording, tracking of inhaler use, displaying environmental alerts, and providing medication reminders. Benefits of these tools include the ability to longitudinally collect symptom, trigger, and inhaler usage data, allowing the detection of significant changes over time to help patients and their caregivers determine whether symptoms are worsening. In addition, data from external information sources, including weather, allergen, and air quality reports, can be integrated with user-specific data to enhance predictions on when patients may experience symptoms and/or need to avoid triggers. Barriers to adoption of asthma-related apps and inhaler-based devices include uncertain efficacy and effectiveness, potential high cost, sustained user engagement, and concerns about privacy. Moreover, ensuring the acceptability and utility of asthma management apps for individuals of all races/ethnicities, socioeconomic groups, ages, genders, and literacy levels is necessary. Based on studies thus far, mobile health apps and inhaler-based devices have great potential to serve as useful tools in the patient-doctor relationship and revolutionize asthma care.

A user-centered, learning asthma smartphone application for patients and providers

PROBLEM

Smartphone applications are an increasingly useful part of patients' self-management of chronic health conditions. Asthma is a common chronic health condition for which good self-management by patients is very helpful in maintaining stability. User-centered design and intelligent systems that learn are steps forward in building applications that are more effective in providing quality care that is scalable and tailored to each patient.

METHODS

A literature and application store search to review historic and current asthma smart phone applications. User-centered design is a methodology that involves all stakeholders of a proposed system from the beginning of the design phase to the end of installation. One aspect of this user-centered approach involved conducting focus groups with patients and health care providers to determine what features they desire for use in applications and create a model to build smart infrastructure for a learning health care system. A simple prototype for an asthma smartphone application is designed and built with basic functionality.

OUTCOMES

Only one publication in the literature review of asthma smartphone applications describes both user-centered design and intelligent learning systems. The authors have presented a set of user-desired attributes for a smart health care application and a possible data flow diagram of information for a learning system. A prototype simple user-centered designed asthma smartphone application that better assists patients in their care illustrates the value of the proposed architecture.

DISCUSSION

Our user-centered approach helped design and implement a learning prototype smart phone application to help patients better manage their asthma and provide information to clinical care providers. While popular in other industries, user-centered design has had slow adoption in the health care area. However, the popularity of this approach is increasing and will hopefully result in mobile application that better meets the needs of both patients and their care providers.

Factors Affecting Patients' Acceptance of and Satisfaction with Cloud-Based Telehealth for Chronic Disease Management: A Case Study in the Workplace

OBJECTIVE

Understanding patients' acceptance of and satisfaction with telehealth use is important for workplace health promotion. In this study, we used a questionnaire to measure patients' usage behavior and satisfaction with cloud-based telehealth services in the workplace. We empirically investigated the factors that influence patients' usage and satisfaction based on data collected from 101 participants.

METHODS

As its main research framework, this study utilized a revised version of the technology acceptance model 2 that was based on the telehealth services provided for chronic disease management. Through integrating a cross-sectional research design with an author-developed structured questionnaire that was assessed using reliability and validity tests, an anonymous survey was conducted on selected participants. The proposed research model and hypotheses were validated through path analysis using SPSS.

RESULTS

We found that users believe telehealth services can promote their workplace health management; that job relevance, result demonstrability, and perceived ease of use (PEOU) positively affect the perceived usefulness (PU), which implies that cognitive instrumental processes have the most significant impact on the PU of cloud-based telehealth; and that both PEOU and PU positively affect the intention to use (IU), but PU has a bigger influence than PEOU on users' intentions to continue using telehealth. In particular, the IU and actual usage behavior were critical to the patients' satisfaction with telehealth services.

CONCLUSION

This research contributes to the rapid developing field of technology acceptance research by examining workplace telemedicine engagement. Our results will provide researchers with useful advice and a user-centered strategy for promoting workplace health management, which benefits both health care providers and corporate managers.

The Future of Asthma Care: Personalized Asthma Treatment

Although once considered a single disease entity, asthma is now known to be a complex inflammatory disease engaging a range of causal pathways. The most frequent forms of asthma are identified by sputum/blood eosinophilia and activation of type 2 inflammatory pathways involving interleukins-3, -4, -5, and granulocyte-macrophage colony-stimulating factor. The use of diagnostics that identify T2 engagement linked to the selective use of highly targeted biologics has opened up a new way of managing severe disease. Novel technologies, such as wearables and intelligent inhalers, enable real-time remote monitoring of asthma, creating a unique opportunity for personalized health care.

Enhancing Asthma Patients' Self-Management through Smartphone-Based Application: Design, Usability Evaluation, and Educational Intervention

OBJECTIVE

The aim of this study was to design and evaluate a smartphone-based application for improving self-management in patients with asthma and evaluate its effects on their knowledge.

METHODS

In this applied research, based on the Clinical Practice Guideline and a systematic review, a questionnaire was designed to determine the application information content and functionality requirements by 15 pediatric and adult asthma and allergy specialist. Then the application was designed and developed using Adobe Air software on the Android operating system. Usability evaluation of the mobile application was performed using the standard questionnaire for user interaction satisfaction (QUIS), which completed by 30 patients with asthma, 8 information technology (IT) specialists, and 2 asthma and allergy specialists. Self-management knowledge of 30 asthma patients was measured using a researcher-made questionnaire before and after using the application.

RESULTS

The number of specialists in the both Delphi rounds was 15 and the mean work experiences were 17.6 years. The most important elements for asthma self-management were avoiding exposure to allergen and triggers (96%), drug treatment (94.6%), and how to use the therapeutic tools (92.4%), and the most important functionalities were alerting the patients when they did not control asthma (92%), setting reminders for timely drug use (85.4%) and therapeutic tools (82.6%), recording prescription drugs (82.6%), and peak flow meter values (82%). Usability evaluation showed that 30 patients with asthma, 8 IT specialists, and 2 physicians evaluated the application at a "good" level. The mean score of the patients' knowledge before intervention was 2.43 ± 0.95 which after intervention was significantly increased to 4.3 ± 0.56 (p < 0.001).

CONCLUSION

Considering the desirable outcomes of application evaluation and a positive impact of this educational intervention on asthma patients' knowledge, it is possible to use mobile-based self-management programs to help these patients to manage illness and gain knowledge and self-management skills.

A Clinically Integrated mHealth App and Practice Model for Collecting Patient-Reported Outcomes between Visits for Asthma Patients: Implementation and Feasibility

OBJECTIVE

Mobile health (mHealth) apps may prove to be useful tools for supporting chronic disease management. We assessed the feasibility of implementing a clinically integrated mHealth app and practice model to facilitate between-visit asthma symptom monitoring as per guidelines and with the help of patient-reported outcomes (PRO).

METHODS

We implemented the intervention at two pulmonary clinics and conducted a mixed-methods analysis of app usage data and semi-structured interview of patients and clinician participants over a 25-week study period.

RESULTS

Five physicians, 1 physician's assistant, 1 nurse, and 26 patients participated. Twenty-four patients (92%) were still participating in the intervention at the end of the 25-week study period. On average, each patient participant completed 21 of 25 questionnaires (84% completion rate). Weekly completion rates were higher for participants who were female (88 vs. 73%, p = 0.02) and obtained a bachelor's degree level or higher (94 vs. 74%, p = 0.04). On average, of all questionnaires, including both completed and not completed (25 weekly questionnaires times 26 patient participants), 25% had results severe enough to qualify for a callback from a nurse; however, patients declined this option in roughly half of the cases in which they were offered the option. We identified 6 key themes from an analysis of 21 patients and 5 clinician interviews. From the patient's perspective, these include more awareness of asthma, more connected with provider, and app simplicity. From the clinician's perspective, these include minimal additional work required, facilitating triage, and informing conversations during visits.

CONCLUSION

Implementation of a clinically integrated mHealth app and practice model can achieve high patient retention and adherence to guideline-recommended asthma symptom monitoring, while minimally burdening clinicians. The intervention has the potential for scaling to primary care and reducing utilization of urgent and emergency care.

A Systematic Review of Patient-Facing Visualizations of Personal Health Data

OBJECTIVES

As personal health data are being returned to patients with increasing frequency and volume, visualizations are garnering excitement for their potential to facilitate patient interpretation. Evaluating these visualizations is important to ensure that patients are able to understand and, when appropriate, act upon health data in a safe and effective manner. The objective of this systematic review was to review and evaluate the state of the science of patient-facing visualizations of personal health data.

METHODS

We searched five scholarly databases (PubMed, Embase, Scopus, ACM Digital Library [Association for Computing Machinery Digital Library], and IEEE Computational Index [Institute of Electrical and Electronics Engineers Computational Index]) through December 1, 2018 for relevant articles. We included English-language articles that developed or tested one or more patient-facing visualizations for personal health data. Three reviewers independently assessed quality of included articles using the Mixed methods Appraisal Tool. Characteristics of included articles and visualizations were extracted and synthesized.

RESULTS

In 39 articles included in the review, there was heterogeneity in the sample sizes and methods for evaluation but not sample demographics. Few articles measured health literacy, numeracy, or graph literacy. Line graphs were the most common visualization, especially for longitudinal data, but number lines were used more frequently in included articles over past 5 years. Article findings suggested more patients understand the number lines and bar graphs compared with line graphs, and that color is effective at communicating risk, improving comprehension, and increasing confidence in interpretation.

CONCLUSION

In this review, we summarize types and components of patient-facing visualizations and methodologies for development and evaluation in the reviewed articles. We also identify recommendations for future work relating to collecting and reporting data, examining clinically actionable boundaries for diverse data types, and leveraging data science. This work will be critically important as patient access of their personal health data through portals and mobile devices continues to rise.

Design and Comprehension Testing of Tailored Asthma Control Infographics for Adults with Persistent Asthma

BACKGROUND

Adherence to daily inhaled corticosteroid medication is important for asthma control but low health literacy is a barrier to comprehension of control status and may contribute to medication nonadherence. Infographics tailored with patients' own data can support comprehension of health status, but these have not been applied to asthma successfully.

OBJECTIVES

This two-phased study developed and tested tailored infographics of (1) scores on the Asthma Control Questionnaire (ACQ), a self-report measure of symptom burden, and (2) pulmonary function test (PFT) results. The infographics are intended for use as communication and adherence-promotion tools in clinical interactions.

METHODS

For both phases, participants (18+ years, English- or Spanish-speaking, persistent asthma) were recruited through two primary care clinics. In Phase I, we used a hybrid iterative participatory design process to refine prototype designs. In Phase II, we conducted individual comprehension assessment interviews with the finalized designs. Infographics were hand-tailored for each participant using their ACQ score and PFT results collected at the start of the interview. Two independent raters scored interview transcripts for gist and verbatim comprehension based on a predetermined rubric.

RESULTS

The five Phase I design sessions led to final prototypes that participants (n = 21) considered appealing and easy to comprehend. All Phase II participants (n = 10) demonstrated complete gist and verbatim comprehension. Participants reacted favorably to receiving their information via infographics and expressed intentions to engage in self-management behaviors (e.g., medication adherence, smoking cessation, weight loss, and review of their care plan) in response to the information.

CONCLUSION

This study provides preliminary evidence that infographics can support comprehension of asthma control status and promote self-management intentions among adults with persistent asthma. Infographics can be programmed into electronic health records and/or standalone applications to allow for instant tailoring at the point of care.

Self-Care Support for Patients with Gastrointestinal Cancer: iCancerHealth

BACKGROUND

Patient-centered symptom assessment and management tools allow patients to perform self-assessments and engage in self-symptom management. Efficacious tools exist for reducing symptom distress; however, little is known about feature-specific use.

OBJECTIVES

This article evaluates the feasibility of the iCancerHealth app as an adjunct to usual patient education regarding cancer symptoms and medication management.

METHODS

We conducted a single-arm, pilot study grounded in the health outcomes model. Our evaluation included (1) enrollment rates, (2) 2-month utilization rates, (3) patient acceptability, and (4) clinician satisfaction with the provider-side application. English-speaking, adult patients receiving care in the gastrointestinal oncology service of a comprehensive cancer center were invited to participate. Research coordinators enrolled consenting participants who had a personal, Internet-connected device; participants registered and used the platform to complete the baseline symptom assessment in clinic. Participants were reminded weekly to use the app and to perform a symptom report 4 to 6 weeks later.

RESULTS

A total of 64 patients were approached, of which 57 (89%; 95% exact confidence interval [CI], 79-96%) enrolled. About half were ≥ 60 years old and 40% were women. Fifty-three patients (93%; 95% exact CI, 85-99%) accessed at least one app feature, at least once, from home. The most frequently used (86%) feature was Health Tracker in which participants monitored and reported symptoms; followed by My Inbox (63%) and My Medications features (60%). The mean acceptability score was 24.8 (standard deviation = 4.2), indicating good acceptability. Clinicians reported that the app was most acceptable with regard to facilitating in-person interactions that occurred after app use.

CONCLUSION

In a sample of adults with various stages of gastrointestinal malignancies, the iCancerHealth app was utilized at a high rate. Features that focused on symptoms and medication side effects plus communication with clinicians were used most frequently. This extends our understanding of preferences and specific feature use with patient-centered technologies.