Telemedicine-Based Provision of Adolescent Gender-Affirming Medical Care to Promote Equitable Access

Purpose: To explore transgender and nonbinary (TNB) young adults' (1) interest in receiving gender-affirming medications through telemedicine before age 18 years and (2) willingness to initiate this care with primary care providers (PCPs). Methods: Data were from a survey of TNB young adults who had not received gender-affirming medications before age 18 years. Chi-square and Wald tests identified demographic differences in telemedicine interest and willingness to initiate medications with their PCP as minors. Results: Among 280 respondents, 82.5% indicated interest in telemedicine and 42.0% were willing to initiate medications with their PCP. Black/African American respondents were more likely to indicate interest in telemedicine than White and multiracial respondents. Respondents from rural areas were more likely to indicate willingness to initiate medications with their PCP than those from urban areas. Conclusions: Telemedicine expansion and further support for PCPs may represent critical opportunities to promote equitable access to adolescent gender-affirming care.

Evaluating an Electronic Consultation Platform to Support Pediatric Primary Care Providers in Caring for Transgender and Nonbinary Adolescents

Background: An electronic consultation (e-consult) platform was implemented to support pediatric primary care providers (PCPs) in providing gender-affirming care to transgender and nonbinary (TNB) adolescents. Following implementation, a study was conducted to (1) explore how access to this e-consult platform impacts PCP confidence and referral patterns, (2) describe the content of questions, and (3) evaluate PCP's perspectives regarding platform usability. Methods: Following each submission, providers completed a 17-item survey. A total of 20 providers submitted 38 e-consults and 26 follow-up surveys between October 2021 and December 2022. Results: All PCPs reported a high overall value and increased confidence caring for TNB adolescents. Nearly one in five (19%) felt it allowed them to avoid submitting a specialty referral. Mean System Usability Scale score was 78.2 indicating good usability. Conclusion: This e-consult platform shows great promise in increasing PCP confidence providing gender-affirming care adolescents. More widespread utilization could help improve access to care and decrease specialty care referrals.

Imagining Improved Interactions: Patients' Designs To Address Implicit Bias

Implicit biases may negatively influence healthcare providers' behaviors toward patients from historically marginalized communities, impacting providers' communication style, clinical decision-making, and delivery of quality care. Existing interventions to mitigate negative experiences of implicit biases are primarily designed to increase recognition and management of stereotypes and prejudices through provider-facing tools and resources. However, there is a gap in understanding and designing interventions from patient perspectives. We conducted seven participatory co-design workshops with 32 Black, Indigenous, People of Color (BIPOC), Lesbian, Gay, Bisexual, Transgender, Queer/Questioning (LGBTQ+), and Queer, Transgender, Black, Indigenous, People of Color (QTBIPOC) individuals to design patient-centered interventions that help them address and recover from provider implicit biases in primary care. Participants designed four types of solutions: accountability measures, real-time correction, patient enablement tools, and provider resources. These informatics interventions extend the research on implicit biases in healthcare through inclusion of valuable, firsthand patient perspectives and experiences.

Adolescent and Caregiver Perspectives on Receiving Gender-Affirming Care in Primary Care

BACKGROUND

Transgender and gender-diverse (TGD) adolescents experience barriers to receiving gender-affirming care. Delivering services in the pediatric primary care setting may help facilitate improved access. With this study, we aimed to explore TGD adolescents' and caregivers' experiences receiving primary care services and their perspectives regarding gender-affirming care delivery in pediatric primary care.

METHODS

TGD adolescents aged 14 to 17 and caregivers of TGD adolescents currently receiving gender-affirming medical care participated in 1-hour-long, semi-structured, individual, virtual interviews. Each interview was recorded and transcribed. Transcripts were then individually coded, and themes were generated iteratively by using a reflexive thematic analysis framework. Recruitment of each group continued until thematic saturation was reached.

RESULTS

A total of 33 participants (15 adolescents and 18 caregivers) completed interviews. Adolescent participants (mean age of 15.7 years) predominantly identified as transmasculine or trans male (73%), and caregiver participants were predominantly mothers (83.3%). Four themes were identified, which included (1) barriers, such as microaggressions and poor psychosocial support, (2) benefits, such as existing trusted relationships with primary care providers (PCPs) and convenience, (3) improvement strategies, such as training and interdisciplinary collaboration, and (4) opportunities for integrating primary care and specialty gender-affirming care.

CONCLUSIONS

TGD adolescents and their caregivers reported previous negative interactions with PCPs; however, some desired to receive gender-affirming care in this setting, citing increased convenience, efficiency, and availability. Participants highlighted an ongoing need for further work to provide resources, education, and training to PCPs and their staff and improve PCP-to-specialist communication and collaboration.

Barriers Pediatric PCP's Identify To Providing Gender-Affirming Care For Adolescents

PURPOSE

Both affirming environments and access to gender-affirming medical care have a positive impact on the mental health of transgender and gender diverse (TGD) youth, however, many TGD youth experience barriers in accessing this care. Pediatric primary care providers (PCPs) can play an important role in expanding access to gender-affirming care for TGD youth; however, few currently provide this care. The purpose of this study was to explore pediatric PCPs' perspectives regarding barriers they experience to providing gender-affirming care in the primary care setting.

METHODS

Pediatric PCPs who had sought out support from the Seattle Children's Gender Clinic were recruited via email to participate in semistructured, one-hour Zoom interviews. All interviews were transcribed and then subsequently analyzed in Dedoose qualitative analysis software using a reflexive thematic analysis framework.

RESULTS

Provider participants (n = 15) represented a wide range of experiences with respect to years in practice, number of TGD youth seen, and practice location (urban, rural, suburban). PCPs identified both health system and community-level barriers to providing gender-affirming care to TGD youth. Health system-level barriers included: (1) lack of foundational knowledge and skills, (2) limited clinical decision-making support, and (3) health system design limitations. Community-level barriers included (1) community and institutional biases, (2) provider attitudes regarding gender-affirming care provision, and (3) challenges identifying community resources to support TGD youth.

DISCUSSION

A multitude of health system and community-level barriers must be overcome in the pediatric primary care setting to ensure that TGD youth receive timely, effective, and more equitable gender-affirming care.

"I miss work:" employment experiences and attitudes of adults with acquired disabilities who use assistive technologies

PURPOSE

This study explored employment experiences and attitudes of adults who acquired mobility, motor, and/or communication disabilities and who use assistive technologies.

MATERIALS AND METHODS

Semi-structured interviews were conducted with seven adults about their employment experiences after acquiring their disabilities. After analysis of interview results, six participants completed surveys about their attitudes towards crowdsourcing and remote work.

RESULTS

Findings indicate that adults can continue working with accommodations when they feel supported and valued by their employer. However, participants frequently compared their pre-disability work performance with their post-disability performance and at times, left work because they did not feel they were performing to their own expectations, regardless of the support of their employer. Participants experienced feelings of loss, regret, and identity change after acquiring their disabilities and after leaving work. Most participants did not have specific knowledge of available work alternatives which could accommodate their health and accessibility needs. When presented with accessible work alternatives, the majority of participants increased their interest in learning more about those options.

CONCLUSIONS

Whether through work or other pursuits, individuals in this population retain a strong desire to participate and contribute to society. However, it should not be assumed that adults with acquired disabilities are inherently aware of available, alternative options to traditional work. Future research on increasing awareness of accessible options for societal engagement for this population should be explored.

Understanding Transgender and Gender-Diverse Youth's Experiences Receiving Care via Telemedicine: Qualitative Interview Study

BACKGROUND

Access to virtual care has increased since the beginning of the COVID-19 pandemic, yet little is known about transgender and gender-diverse (TGD) youth's experiences and perspectives on receiving care via telemedicine.

OBJECTIVE

The purpose of this study was to explore these experiences to (1) inform necessary changes to the provision of pediatric gender-affirming care and (2) help providers and health systems determine if and how telemedicine should be made available post pandemic.

METHODS

Youth (aged 14-17 years) who completed a telemedicine visit in the Seattle Children's Gender Clinic were invited to participate in a semistructured interview exploring perceived advantages or disadvantages of telemedicine and preferred visit modalities. Interview transcriptions were analyzed by 2 research team members using an inductive thematic analysis framework.

RESULTS

A total of 15 TGD youth completed an interview. Commonly cited advantages of telemedicine were convenience and comfort with having visits in their own environments. Reported disadvantages included technical issues, discomfort with the impersonal nature, lack of familiarity with the platform, and privacy concerns. Overall, slightly more youth preferred in-person visits over telemedicine, referencing both specific characteristics of the clinical visit (ie, initial vs return and complexity) and proximity to the clinic as reasons for this preference. Although a plurality of TGD youth preferred in-person visits, they also recognized the value of telemedicine and the impact it may have in facilitating access to care.

CONCLUSIONS

Given the variations in needs and visit complexity, our study supports the provision of both in-person and telemedicine modalities as options for pediatric gender-affirming care.

Pediatric Primary Care Providers' Perspectives on Telehealth Platforms to Support Care for Transgender and Gender-Diverse Youths: Exploratory Qualitative Study

BACKGROUND

Access to gender-affirming care services for transgender and gender-diverse youths is limited, in part because this care is currently provided primarily by specialists. Telehealth platforms that enable primary care providers (PCPs) to receive education from and consult specialists may help improve the access to such services. However, little is known about PCPs' preferences regarding receiving this support.

OBJECTIVE

This study aimed to explore pediatric PCPs' perspectives regarding optimal ways to provide telehealth-based support to facilitate gender-affirming care provision in the primary care setting.

METHODS

PCPs who had previously requested support from the Seattle Children's Gender Clinic were recruited to participate in semistructured, 1-hour web-based interviews. Overall, 3 specialist-to-PCP telehealth modalities (tele-education, electronic consultation, and telephonic consultation) were described, and the participants were invited to share their perspectives on the benefits and drawbacks of each modality, which modality would be the most effective, and the most important characteristics or outcomes of a successful platform. Interviews were transcribed and analyzed using a reflexive thematic analysis framework.

RESULTS

The interviews were completed with 15 pediatric PCPs. The benefits of the tele-education platform were developing a network with other PCPs to facilitate shared learning, receiving comprehensive didactic and case-based education, having scheduled education sessions, and increasing provider confidence. The drawbacks were requiring a substantial time commitment and not allowing for real-time, patient-specific consultation. The benefits of the electronic consultation platform were convenient and efficient communication, documentation in the electronic health record, the ability to bill for provider time, and sufficient time to synthesize information. The drawbacks of this platform were electronic health record-related difficulties, text-based communication challenges, inability to receive an answer in real time, forced conversations with patients about billing, and limitations for providers who lack baseline knowledge. With respect to telephonic consultation, the benefits were having a dialogue with a specialist, receiving compensation for PCP's time, and helping with high acuity or complex cases. The drawbacks were challenges associated with using the phone for communication, the limited expertise of the responding providers, and the lack of utility for nonemergent issues. Regarding the most effective platform, the responses were mixed, with 27% (4/15) preferring the electronic consultation, 27% (4/15) preferring tele-education, 20% (3/15) preferring telephonic consultation, and the remaining 27% (4/15) suggesting a hybrid of the 3 models.

CONCLUSIONS

A diverse suite of telehealth-based training and consultation services must be developed to meet the needs of PCPs with different levels of experience and training in gender-affirming care. Beyond the widely used telephonic consultation model, electronic consultation and tele-education may provide important alternative training and consultation opportunities to facilitate greater PCP independence and promote wider access to gender-affirming care.

Maybe they had a bad day: how LGBTQ and BIPOC patients react to bias in healthcare and struggle to speak out

OBJECTIVE

People who experience marginalization, including Black, Indigenous, People of Color (BIPOC) and Lesbian, Gay, Bisexual, Transgender, Queer, Plus (ie, all other marginalized genders and sexual orientations) people (LGBTQ+) experience discrimination during healthcare interactions, which negatively impacts patient-provider communication and care. Yet, scarce research examines the lived experience of unfair treatment among patients from marginalized groups to guide patient-centered tools that improve healthcare equity.

MATERIALS AND METHODS

We interviewed 25 BIPOC and/or LGBTQ+ people about their experiences of unfair treatment and discrimination when visiting healthcare providers. Through thematic analysis, we describe participants' immediate reactions and longer-term consequences of those experiences.

RESULTS

We identified 4 ways that participants reacted to discrimination in the moment: Fighting, Fleeing, Excusing, and Working Around Bias. Long-term consequences reflect 6 ways they coped: Delaying or Avoiding Care, Changing Healthcare Providers, Self-prescribing, Covering Behaviors, Experiencing Health Complications, and Mistrusting Healthcare Institutions.

DISCUSSION

By describing how patients react to experiences of unfair treatment and discrimination, our findings enhance the understanding of health disparities as patients cope and struggle to speak out.To combat these problems, we identify 3 future directions for informatics interventions that improve provider behavior, support patient advocacy, and address power dynamics in healthcare.

CONCLUSIONS

BIPOC and LGBTQ+ patients' perspectives on navigating unfair treatment and discrimination in healthcare offers critical insight into their experiences and long-term consequences of those experiences. Understanding the circumstances and consequences of unfair treatment, discrimination, and the impact of bias through this patient-centered lens is crucial to inform informatics technologies that promote health equity.

My Kidney Identity: Contextualizing pediatric patients and their families kidney transplant journeys

BACKGROUND

Even though having a kidney transplant is the treatment of choice for children with kidney failure, it can cause anxiety for patients and their families resulting in decreased psychosocial functioning, adherence, and self-management. We set out to identify the information needs required to help pediatric patients and their families contextualize their posttransplant experiences as they recalibrate their understanding of normalcy throughout their transplant journey.

METHODS

Participants submitted photographs related to feeling: (1) worried, (2) confident, (3) similar to peers without kidney disease, and (4) different from these peers. The photographs served as a foundation for an in-depth interview.

RESULTS

Nineteen individuals (10 pediatric transplant recipients and 9 caregivers) were interviewed at a mean of 8 years posttransplant. We identified five specific themes and tensions our participants associated with recalibrating their version of "normal" throughout the transplant journey: (1) exchanging information (information consumers vs. information contributors, (2) transitional management (family management vs. self-management), (3) building confidence (worry vs. confidence), (4) telling one's story (hiding vs. self-expression), and (5) normalizing kidney transplantation (feeling different vs. feeling similar). These five themes/tensions form one's Kidney Identity, shift from negative to positive throughout the transplant journey, illustrating a more abstract and complex account of kidney transplantation over time.

CONCLUSIONS

Having a patient view their Kidney Identity over time may support self-reflection of one's progress posttransplant and potentially help clinicians, patients, and their caregivers identify barriers and areas where they may need more support to ensure their successful engagement in their care.

Battling Bias in Primary Care Encounters: Informatics Designs to Support Clinicians

Although clinical training in implicit bias is essential for healthcare equity, major gaps remain both for effective educational strategies and for tools to help identify implicit bias. To understand the perspectives of clinicians on the design of these needed strategies and tools, we conducted 21 semi-structured interviews with primary care clinicians about their perspectives and design recommendations for tools to improve patient-centered communication and to help mitigate implicit bias. Participants generated three types of solutions to improve communication and raise awareness of implicit bias: digital nudges, guided reflection, and data-driven feedback. Given the nuance of implicit bias communication feedback, these findings illustrate innovative design directions for communication training strategies that clinicians may find acceptable. Improving communication skills through individual feedback designed by clinicians for clinicians has the potential to improve healthcare equity.

Children's Designs for the Future of Telehealth

Telehealth has increased dramatically with COVID-19. However, current telehealth systems are designed for able-bodied adults, rather than for pediatric populations or for people with disabilities. Using a design scenario of a child with a communication disability who needs to access telehealth services, we explore children's ideas of the future of telehealth technology. We analyzed designs generated by six children and found three provocative over-arching design themes. The designs highlight how improving accessibility, accommodating communication preferences, and incorporating home based sensor technologies have the potential to improve telehealth for both pediatric patients and their physicians. We discuss how these themes can be incorporated into practical telehealth designs to serve a variety of patient populations-including adults, children, and people with disabilities.

Telehealth experiences of providers and patients who use augmentative and alternative communication

OBJECTIVE

We explore the telehealth experiences of adults who use augmentative and alternative communication (AAC) and clinicians who work with people using AAC.

MATERIALS AND METHODS

We conducted semistructured, online interviews with 6 adults who use AAC and 8 clinicians who provide telehealth services to people who use AAC between July and September 2020. Participants were located in the United States and the United Kingdom. All participants had engaged in 2 or more telehealth visits in the past 6 months. We used an inductive, thematic approach to analyze the interview data.

RESULTS

Our findings reveal that (1) telehealth is an essential service, (2) technology causes barriers, (3) policies meant to protect actually inhibit, and (4) remote monitoring devices have the potential to mitigate risks.

DISCUSSION

Telehealth systems created for persons without disabilities do not provide equitable access to everyone. Telehealth should be flexible enough to allow patients to use the communication modality that best meets their needs. We suggest that healthcare systems think of the healthcare ecosystem as one which includes a variety of telehealth options in addition to traditional in-person clinical visits.

CONCLUSIONS

The benefits of telehealth for people who use AAC are substantial and should be an option for ongoing health care. However, the accessibility of telehealth technologies needs to be improved. Designers should view telehealth as part of a broad healthcare ecosystem, which includes in-person, telehealth, and remote health monitoring technologies. Designers should also include AAC users in the design and development process. Telehealth policies should encourage multimodality access to health care and address funding concerns.

Microaggression clues from social media: revealing and counteracting the suppression of women's health care

OBJECTIVE

The purpose of this study was to demonstrate how analyzing social media posts can uncover microaggressions and generate new cultural insights. We explore why Korean women hesitate to seek recommended gynecological care and how microaggressions visible in social media reveal insights for counteracting such harmful messaging.

MATERIALS AND METHODS

We scraped the posts and responses on social media related to unmarried women's uncomfortableness or unpleasantness in receiving gynecological care. We conducted content analyses of the posts and responses with the microaggression framework to identify both the types of microaggressions occurring within and outside the clinic as well as the responsible perpetrators. With an open-coding and subsequent deductive coding approach, we further investigated the socio-cultural context for receiving gynecological care as an unmarried woman in South Korea.

RESULTS

Our analysis uncovered that mothers, male partners, and superficially supportive social media responders contribute to pre- and post-visit microaggressions toward unmarried women seeking gynecological care whereas healthcare providers contribute to only mid-visit microaggressions. We also exposed how social media was not only revealing but also reinforcing the suppression of women's health care.

DISCUSSION

Mid-visit microaggressions are currently addressed by cultural competence education, but pre- and post-visit microaggressions are overlooked. We uncover the gaps in current practices of informatics and public health methods and suggest ways to counteract online and offline microaggressions.

CONCLUSIONS

Social media provides valuable information about the cultural context of health care and should be used as a source of insights for targeted interventions to improve health care, in this case for unmarried Korean women.

Different roles with different goals: Designing to support shared situational awareness between patients and clinicians in the hospital

Objective

Team situational awareness helps to ensure high-quality care and prevent errors in the complex hospital environment. Although extensive work has examined factors that contribute to breakdowns in situational awareness among clinicians, patients’ and caregivers’ roles have been neglected. To address this gap, we studied team-based situational awareness from the perspective of patients and their caregivers.

Materials and Methods

We utilized a mixed-methods approach, including card sorting and semi-structured interviews with hospitalized patients and their caregivers at a pediatric hospital and an adult hospital. We analyzed the results utilizing the situational awareness (SA) theoretical framework, which identifies 3 distinct stages: (1) perception of a signal, (2) comprehension of what the signal means, and (3) projection of what will happen as a result of the signal.

Results

A total of 28 patients and 19 caregivers across the 2 sites participated in the study. Our analysis uncovered how team SA helps patients and caregivers ensure that their values are heard, their autonomy is supported, and their clinical outcomes are the best possible. In addition, our participants described both barriers—such as challenges with communication—and enablers to facilitating shared SA in the hospital.

Discussion

Patients and caregivers possess critical knowledge, expertise, and values required to ensure successful and accurate team SA. Therefore, hospitals need to incorporate tools that facilitate patients and caregivers as key team members for effective SA.

Conclusions

Elevating patients and caregivers from passive recipients to equal contributors and members of the healthcare team will improve SA and ensure the best possible outcomes.

User-centered design of a longitudinal care plan for children with medical complexity

OBJECTIVE

To determine the content priorities and design preferences for a longitudinal care plan (LCP) among caregivers and healthcare providers who care for children with medical complexity (CMC) in acute care settings.

MATERIALS AND METHODS

We conducted iterative one-on-one design sessions with CMC caregivers (ie, parents/legal guardians) and providers from 5 groups: complex care, primary care, subspecialists, emergency care, and care coordinators. Audio-recorded sessions included content categorization activities, drawing exercises, and scenario-based testing of an electronic LCP prototype. We applied inductive content analysis of session materials to elicit content priorities and design preferences between sessions. Analysis informed iterative prototype revisions.

RESULTS

We conducted 30 design sessions (10 with caregivers, 20 with providers). Caregivers expressed high within-group variability in their content priorities compared to provider groups. Emergency providers had the most unique content priorities among clinicians. We identified 6 key design preferences: a familiar yet customizable layout, a problem-based organization schema, linked content between sections, a table layout for most sections, a balance between unstructured and structured data fields, and use of family-centered terminology.

DISCUSSION

Findings from this study will inform enhancements of electronic health record-embedded LCPs and the development of new LCP tools and applications. The design preferences we identified provide a framework for optimizing integration of family and provider content priorities while maintaining a user-tailored experience.

CONCLUSION

Health information platforms that incorporate these design preferences into electronic LCPs will help meet the information needs of caregivers and providers caring for CMC in acute care settings.

Use and impact of an online community for hospital patients

OBJECTIVE

Although patient-peer support technologies have demonstrated effectiveness in a variety of health contexts-including diabetes, weight loss, and cancer-less is known about how hospitalized patients can benefit from this support. We investigated the nature of peer support in the hospital and the impact this support had on patients' hospital stays.

MATERIALS AND METHODS

We created a technology, resembling an online health community, in which patients could exchange advice about their hospitalization. We deployed it at 1 pediatric hospital and 1 adult hospital. With 30 participants, we conducted bedside interviews, observed how they used the technology during their hospitalization, and completed follow-up phone interviews.

RESULTS

Participants shared advice about several topics, including adjusting to the hospital and building relationships with providers. Contrary to concerns that such a system would primarily serve as a place for patients to "complain," sentiment analysis showed that 23 of 36 (64%) of the shared advice reflected positive sentiment. Patients also reported positive impacts to their quality, safety, and hospital experience due to the inpatient peer support community.

DISCUSSION

Participants benefited from peer support that transcended diagnoses and individual health conditions. The shared experience of being in the hospital was sufficient to yield valuable and practical peer support. Participants who did not contribute their own advice still experienced benefits from reading their peers' advice.

CONCLUSIONS

Our study demonstrated the positive nature of peer advice exchanged, and the benefits of this advice on patients' hospital stays. Inpatient peer support technologies could be an additional resource for patients to engage in their care.

Informatics opportunities to involve patients in hospital safety: a conceptual model

Objective

Inpatients could play an important role in identifying, preventing, and reporting problems in the quality and safety of their care. To support them effectively in that role, informatics solutions must align with their experiences. Thus, we set out to understand how inpatients experience undesirable events (UEs) and to surface opportunities for those informatics solutions.

Materials and Methods

We conducted a survey with 242 patients and caregivers during their hospital stay, asking open-ended questions about their experiences with UEs. Based on our qualitative analysis, we developed a conceptual model representing their experiences and identified informatics opportunities to support patients.

Results

Our 4-stage conceptual model illustrates inpatient experiences, from when they first encounter UEs, when they could intervene, when harms emerge, what types of harms they experience, and what they do in response to harms.

Discussion

Existing informatics solutions address the first stage of inpatients’ experiences by increasing their awareness of potential UEs. However, future researchers can explore new opportunities to fill gaps in support that patients experience in subsequent stages, especially at critical decision points such as intervening in UEs and responding to harms that occur.

Conclusions

Our conceptual model reveals the complex inpatient experiences with UEs, and opportunities for new informatics solutions to support them at all stages of their experience. Investigating these new opportunities could promote inpatients’ participation and engagement in the quality and safety of their care, help healthcare systems learn from inpatients’ experience, and reduce these harmful events.

Designing Inpatient Portals to Support Patient Agency and Dynamic Hospital Experiences

Inpatient portals could help patients engage in their hospital care, yet several design, usability, and adoption issues prevent this technology from fulfilling its potential. Despite patients having needs that extend beyond the scope of existing inpatient portals, we know less about how to design such portals that support them. To learn about effective designs, we created three mid-fidelity prototypes representing novel approaches for inpatient portal design. Then, we conducted interviews with 21 pediatric and adult inpatients to gather their feedback on these prototypes. Participants shared how the prototypes addressed the following needs: forming active partnerships, navigating relationships and power dynamics with clinicians, understanding complexity of care, contextualizing health information, increasing efficiency of communication, and preventing lost information. We discuss two key implications-supporting patients' agency and dynamic needs throughout their hospital care-for the future of inpatient portal designs.

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.

Broken down by bias: Healthcare biases experienced by BIPOC and LGBTQ+ patients

Bias toward historically marginalized patients affects patient-provider interactions and can lead to lower quality of care and poor health outcomes for patients who are Black, Indigenous, People of Color (BIPOC) and Lesbian, Gay, Bisexual, Transgender and Gender Diverse (LGBTQ+). We gathered experiences with biased healthcare interactions and suggested solutions from 25 BIPOC and LGBTQ+ people. Through qualitative thematic analysis of interviews, we identified ten themes. Eight themes reflect the experience of bias: Transactional Care, Power Inequity, Communication Casualties, Bias-Embedded Medicine, System-level problems, Bigotry in Disguise, Fight or Flight, and The Aftermath. The remaining two themes reflect strategies for improving those experiences: Solutions and Good Experiences. Characterizing these themes and their interconnections is crucial to design effective informatics solutions that can address biases operating in clinical interactions with BIPOC and LGBTQ+ patients, improve the quality of patient-provider interactions, and ultimately promote health equity.

Using Priorities of Hospitalized Patients and Their Caregivers to Develop Personas

Hospitalized patients and their caregivers often access technologies like patient portals to understand what happens during their hospital stay. Although this access can lead to more patient engagement and positive health outcomes, many find that the technology does not support their needs. As a first step toward improving patient-facing technologies we create personas for hospitalized patients and their caregivers by following the Q Methodology, a technique for quantifying subjective opinion. We clustered 28 hospitalized patients' and 19 caregivers' attitudes towards receiving and managing information and working with their care team. We contribute three patient personas: patients who are (1) accommodating information seekers, (2) involved safety guardians, and (3) self-managing participators. We identify three caregiver personas: (1) cooperative information seekers, (2) vocal participators, and (3) hands-off safety guardians. These personas can inform future tools designed to support communication and information management for hospitalized patients and caregivers.

Design for Social Accessibility Method Cards

This article is an extended version of our 2018 ASSETS paper entitled, “Incorporating Social Factors in Accessible Design.” In our ASSETS paper, we demonstrated the viability of the Design for Social Accessibility perspective through a series of user-centered workshops with professional designers. With this expanded article, we conducted a follow-up research study with a user-centered design course that examined the use of Design for Social Accessibility Method Cards over a longer design cycle, specifically as the method and cards contributed to a term-long project, rather than just a workshop. We also offer a new analysis on work leading to the development of Design for Social Accessibility, with a focus on how practical considerations in the design process influence how designers engage accessible design. We found that the concrete and real-life scenarios in the Design for Social Accessibility Method Cards helped mediate useful interactions between student designers and deaf and hard-of-hearing users. In addition, we identified how practical choices in investigating strategies for socially accessible design enabled designers to center disabled perspectives. The contributions of this work—when added to the findings of our ASSETS 2018 paper on incorporating social factors—demonstrate the viability of Design for Social Accessibility by providing: (1) empirical data showing that designers can use the Design for Social Accessibility perspective and method cards to generate accessible designs and appropriately engage deaf and hard-of-hearing users to incorporate social considerations; and (2) a summative analysis highlighting practical steps for how designers can use the Design for Social Accessibility perspective and methods cards to create accessible designs.

Association of Health Record Visualizations With Physicians' Cognitive Load When Prioritizing Hospitalized Patients

IMPORTANCE

Current electronic health records (EHRs) contribute to increased physician cognitive workload when completing clinical tasks.

OBJECTIVE

To assess the association of different design features of an EHR-based information visualization tool with the cognitive load of physicians during the clinical prioritization process.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included a convenience sample of 29 attending physicians at Seattle Children's Hospital, a large tertiary academic pediatric hospital. Data collection took place from August 2017 through October 2017, and analysis occurred from August to October 2018.

EXPOSURE

Physician participants used 3 prototypes with novel visualizations of simulated EHR data that highlighted 1 of 3 key patient characteristics, as follows: (1) acuity, (2) clinical problem list, and (3) clinical change.

MAIN OUTCOMES AND MEASURES

Cognitive workload was measured using the NASA Task Load Index (TLX) scale (range, 1-100, with lower scores indicating lower cognitive workload). Cognitive workload was assessed for the 2 following clinical prioritization tasks: (1) finding information for a specific patient and (2) comparing results among patients for each prototype. Participants ranked 5 hypothetical patients from having the highest to the lowest priority in each design.

RESULTS

A total of 29 physician participants (15 [52%] men; 14 [48%] women; mean [range] age, 43 [35-58] years; mean [range] time in practice, 11 [3-30] years) completed the study. For task 1, the prototype highlighting clinical change was associated with lower median (interquartile range) NASA TLX scores compared with the prototype highlighting acuity (30.3 [15.2-41.6] vs 48.5 [18.7-59.3]; P = .02). For task 2, the prototype highlighting clinical change was associated with lower median (interquartile range) NASA TLX scores compared with the prototype highlighting the clinical problem list (29.1 [16.3-50.8] vs 43.5 [26.6-55.9]; P = .02). The prototype highlighting clinical change had the lowest TLX score in 17 of 29 rankings (59%) for task 1 (χ24 = 24.4; P < .001) and 18 of 29 rankings (62%) for task 2 (χ24 = 17.2; P = .002).

CONCLUSIONS AND RELEVANCE

In this study, well-designed EHR-based information visualizations that highlighted and featured clinically meaningful information patterns significantly reduced physician cognitive workload when prioritizing patient needs.

Communicating Bad News: Insights for the Design of Consumer Health Technologies

Background

As people increasingly receive personal health information through technology, there is increased importance for this information to be communicated with empathy and consideration for the patient’s experience of consuming it. Although technology enables people to have more frequent and faster access to their health information, it could also cause unnecessary anxiety, distress, or confusion because of the sensitive and complex nature of the information and its potential to provide information that could be considered bad news.

Objective

The aim of this study was to uncover insights for the design of health information technologies that potentially communicate bad news about health such as the result of a diagnosis, increased risk for a chronic or terminal disease, or overall declining health.

Methods

On the basis of a review of established guidelines for clinicians on communicating bad news, we developed an interview guide and conducted interviews with patients, patients’ family members, and clinicians on their experience of delivering and receiving the diagnosis of a serious disease. We then analyzed the data using a thematic analysis to identify overall themes from a perspective of identifying ways to translate these strategies to technology design.

Results

We describe qualitative results combining an analysis of the clinical guidelines for sharing bad health news with patients and interviews on clinicians’ specific strategies to communicate bad news and the emotional and informational support that patients and their family members seek. Specific strategies clinicians use included preparing for the patients’ visit, anticipating patients’ feelings, building a partnership of trust with patients, acknowledging patients’ physical and emotional discomfort, setting up a scene where patients can process the information, helping patients build resilience and giving hope, matching the level of information to the patients’ level of understanding, communicating face-to-face, if possible, and using nonverbal means. Patient and family member experiences included internal turmoil and emotional distress when receiving bad news and emotional and informational support that patients and family members seek.

Conclusions

The results from this study identify specific strategies for health information technologies to better promote empathic communication when they communicate concerning health news. We distill the findings from our study into design hypotheses for ways technologies may be able to help people better cope with the possibility of receiving bad health news, including tailoring the delivery of information to the patients’ individual preferences, supporting interfaces for sharing patients’ context, mitigating emotional stress from self-monitoring data, and identifying clear, actionable steps patients can take next.

Creating synthetic patient data to support the design and evaluation of novel health information technology

To ensure that new health information technology supports its intended users, researchers and developers need to follow human-centered methods during all stages of the software development lifecycle, including early stage evaluations. These evaluations need to include realistic testing scenarios to ensure that they provide valuable and accurate feedback to system developers. However, obtaining realistic patient data to support these evaluations has many challenges, including the risk of re-identifying anonymized patients as well as the costs associated with connecting test systems with production ready clinical databases. Here we present a novel five-step process to create highly structured and realistic synthetic patient data to support the evaluation and comparison of early to middle stage health information technology prototypes. We applied this method to evaluate and compare three novel health information technology prototypes designed to support clinicians during the identification of high-priority patients when answering the question: "What patient should I see first?" Our novel approach fills an important gap in the evaluation of health information technology and assists designers in creating high-quality software that best supports its end users.

"It's Not Just Technology, It's People": Constructing a Conceptual Model of Shared Health Informatics for Tracking in Chronic Illness Management

Background

For many people, tracking health indicators is central to managing a chronic illness. However, previous informatics research has largely viewed tracking as a solitary process that lacks the characteristics essential to tracking in support of chronic illness management.

Objective

To inform development of effective technologies that aid tracking of health indicators to support chronic illness management, this study aimed to construct a health informatics model that accurately describes the work and social context of that tracking work.

Methods

As part of a larger project, we conducted semistructured interviews with 40 adults concerning their chronic illness management practices, including tracking and communication. We also assembled transcripts of 30 publicly available videos of 24 adults discussing tracking processes for managing their own chronic illness. We used qualitative methods to analyze interviews and video transcripts through the lens of ongoing personal and health informatics research.

Results

We have described the people and work involved in tracking in support of chronic illness management and contributed a Conceptual Model of Shared Health Informatics (CoMSHI). Specifically, we identified the need for a health informatics model that (1) incorporates the ongoing nature of tracking work and (2) represents the social dimension of tracking for illness management. Our model depicts communication, information, collection, integration, reflection, and action work in the social context of the person with chronic illness, informal carers, health care providers, and community members.

Conclusions

The resulting CoMSHI yields a more detailed and nuanced viewpoint of tracking in support of chronic illness management and can inform technology design to improve tracking tools to support people in more confident and capable chronic illness management.

The Value of Patient-Peer Support in Improving Hospital Safety

Healthcare systems worldwide have dedicated several years, special attention, and action toward improving safety for their patients. Although many innovative technological solutions have helped providers reduce medical errors, hospitalized patients lack access to these solutions, and face difficulties in having a proactive role in their safety. In this paper, we examine how patient-peer support can be a valuable resource for patients in the context of hospital safety. Through semi-structured interviews with 30 patients and caregivers at a pediatric and an adult hospital, we identify the potential benefits of incorporating patient-peer support into patient-facing technologies. Facilitating such support can provide patients with new avenues for engaging in, and improving, the quality and safety of their hospital care.

Collaborative Health Reminders and Notifications: Insights from Prototypes

We designed five novel collaborative health reminders using data-driven low-fidelity prototyping methods. Each collaborative reminder-Symbolic Reminder Band, Social Reminder App, Reminder Invitation, Conversation Reminder, and Actionable Notification-was designed for patients to engage, discuss, and share their health information for collaboration on health tasks. We conducted evaluations with 11 patients and caregivers: six patients with type 2 diabetes, and five mothers of children with asthma. We found that participants valued these reminders for enhancing the patient-provider relationship, supporting shared action on health tasks, and promoting social support. We contribute design implications for collaborative health reminders that enhance patient-centered care.

Exploring the Design of an Inpatient Peer Support Tool: Views of Adult Patients

Despite wide recognition of the value, expertise, and support that patient-peers provide in a variety of health contexts, mechanisms to design and enable peer support in the inpatient setting have not been sufficiently explored. To better understand the opportunities for an inpatient peer support tool, we surveyed 100 adult patients and caregivers, and conducted follow-up, semi-structured interviews with 15 adult patients. In this paper, we describe five key peer support needs that our adult patient participants expressed: (1) adjusting to the hospital environment, (2) understanding and normalizing medical care, (3) communicating with providers, (4) reporting and preventing medical errors, and (5) empowering peers. In addition, we identify privacy concerns, situational impairments, and communication mode as barriers to, and preferences for, interacting with peers. Based on our findings, we discuss intelligent peer matching and aggregating peer data as design recommendations for future inpatient peer support tools.

Caregiver and Health Care Provider Perspectives on Cloud-Based Shared Care Plans for Children With Medical Complexity

OBJECTIVES

Shared care plans play an essential role in coordinating care across health care providers and settings for children with medical complexity (CMC). However, existing care plans often lack shared ownership, are out-of-date, and lack universal accessibility. In this study, we aimed to establish requirements for shared care plans to meet the information needs of caregivers and providers and to mitigate current information barriers when caring for CMC.

METHODS

We followed a user-centered design methodology and conducted in-depth semistructured interviews with caregivers and providers of CMC who receive care at a tertiary care children's hospital. We applied inductive, thematic analysis to identify salient themes. Analysis occurred concurrently with data collection; therefore, the interview guide was iteratively revised as new questions and themes emerged.

RESULTS

Interviews were conducted with 17 caregivers and 22 providers. On the basis of participant perspectives, we identified 4 requirements for shared care plans that would help meet information needs and mitigate current information barriers when caring for CMC. These requirements included the following: (1) supporting the accessibility of care plans from multiple locations (eg, cloud-based) and from multiple devices, with alert and search features; (2) ensuring the organization is tailored to the specific user; (3) including collaborative functionality such as real-time, multiuser content management and secure messaging; and (4) storing care plans on a secure platform with caregiver-controlled permission settings.

CONCLUSIONS

Although further studies are needed to understand the optimal design and implementation strategies, shared care plans that meet these specified requirements could mitigate perceived information barriers and improve care for CMC.

Supporting Collaborative Health Tracking in the Hospital: Patients' Perspectives

The hospital setting creates a high-stakes environment where patients' lives depend on accurate tracking of health data. Despite recent work emphasizing the importance of patients' engagement in their own health care, less is known about how patients track their health and care in the hospital. Through interviews and design probes, we investigated hospitalized patients' tracking activity and analyzed our results using the stage-based personal informatics model. We used this model to understand how to support the tracking needs of hospitalized patients at each stage. In this paper, we discuss hospitalized patients' needs for collaboratively tracking their health with their care team. We suggest future extensions of the stage-based model to accommodate collaborative tracking situations, such as hospitals, where data is collected, analyzed, and acted on by multiple people. Our findings uncover new directions for HCI research and highlight ways to support patients in tracking their care and improving patient safety.

Tenets for Social Accessibility

Despite years of addressing disability in technology design and advocating user-centered design practices, popular mainstream technologies remain largely inaccessible for people with disabilities. We conducted a design course study investigating how student designers regard disability and explored how designing for multiple disabled and nondisabled users encouraged students to think about accessibility in the design process. Across two university course offerings one year apart, we examined how students focused on a design project while learning user-centered design concepts and techniques, working with people with and without disabilities throughout the project. In addition, we compared how students incorporated disability-focused design approaches within a classroom setting. We found that designing for multiple stakeholders with and without disabilities expanded student understanding of accessible design by demonstrating that people with the same disability could have diverse needs and by aligning such needs with those of nondisabled users. We also found that using approaches targeted toward designing for people with disabilities complemented interactions with users, particularly with regard to managing varying abilities across users, or incorporating social aspects. Our findings contribute to an understanding about how we might incur change in design practice by working with multiple stakeholders with and without disabilities whenever possible. We refined Design for Social Accessibility by incorporating these findings into three tenets emphasizing: (1) design for disability ought to incorporate users with and without disabilities, (2) design should address functional and social factors simultaneously, and (3) design should include tools to spur consideration of social factors in accessible design.

Sociotechnical Requirements Analysis for Clinical Systems

Objective: We explore sociotechnical requirements by examining the use of a computerized patient record system in an intensive care unit of a U.S. hospital and present two sociotechnical requirements, awareness and coordination, embedded in the users’ work.

Method: The study is based on observation during seven months of the use of a computerized patient record system in a surgical intensive care unit. During that period semi-formal interviews, informal interviews were held.

Results and Conclusions: A key step in the design of clinical systems is the development and analysis of requirements. However, traditional requirements analysis is based on a set of assumptions that break down in the highly collaborative, exception-filled clinical domain. Sociotechnical requirement analysis enabled the designers to gather a much richer description of the environment surrounding the computer system, highlighting awareness and coordination, embedded in the users’ work.

Detecting clinically related content in online patient posts

Patients with chronic health conditions use online health communities to seek support and information to help manage their condition. For clinically related topics, patients can benefit from getting opinions from clinical experts, and many are concerned about misinformation and biased information being spread online. However, a large volume of community posts makes it challenging for moderators and clinical experts, if there are any, to provide necessary information. Automatically identifying forum posts that need validated clinical resources can help online health communities efficiently manage content exchange. This automation can also assist patients in need of clinical expertise by getting proper help. We present our results on testing text classification models that efficiently and accurately identify community posts containing clinical topics. We annotated 1817 posts comprised of 4966 sentences of an existing online diabetes community. We found that our classifier performed the best (F-measure: 0.83, Precision: 0.79, Recall:0.86) when using Naïve Bayes algorithm, unigrams, bigrams, trigrams, and MetaMap Symantic Types. Training took 5 s. The classification process took a fraction of 1 s. We applied our classifier to another online diabetes community, and the results were: F-measure: 0.63, Precision: 0.57, Recall: 0.71. Our results show our model is feasible to scale to other forums on identifying posts containing clinical topic with common errors properly addressed.

Design Recommendations for Pharmacogenomics Clinical Decision Support Systems

The use of pharmacogenomics (PGx) in clinical practice still faces challenges to fully adopt genetic information in targeting drug therapy. To incorporate genetics into clinical practice, many support the use of Pharmacogenomics Clinical Decision Support Systems (PGx-CDS) for medication prescriptions. This support was fueled by new guidelines to incorporate genetics for optimizing drug dosage and reducing adverse events. In addition, the complexity of PGx led to exploring CDS outside the paradigm of the basic CDS tools embedded in commercial electronic health records. Therefore, designing the right CDS is key to unleashing the full potential of pharmacogenomics and making it a part of clinicians' daily workflow. In this work, we 1) identify challenges and barriers of the implementation of PGx-CDS in clinical settings, 2) develop a new design approach to CDS with functional characteristics that can improve the adoption of pharmacogenomics guidelines and thus patient safety, and 3) create design guidelines and recommendations for such PGx-CDS tools.

Opportunities and Design Considerations for Peer Support in a Hospital Setting

Although research has demonstrated improved outcomes for outpatients who receive peer support-such as through online health communities, support groups, and mentoring systems-hospitalized patients have few mechanisms to receive such valuable support. To explore the opportunities for a hospital-based peer support system, we administered a survey to 146 pediatric patients and caregivers, and conducted semi-structured interviews with twelve patients and three caregivers in a children's hospital. Our analysis revealed that hospitalized individuals need peer support for five key purposes: (1) to ask about medical details-such as procedures, treatments, and medications; (2) to learn about healthcare providers; (3) to report and prevent medical errors; (4) to exchange emotional support; and (5) to manage their time in the hospital. In this paper, we examine these themes and describe potential barriers to using a hospital-based peer support system. We then discuss the unique opportunities and challenges that the hospital environment presents when designing for peer support in this setting.

A double-blind randomized controlled trial of ibuprofen compared to placebo for uncomplicated cellulitis of the upper or lower limb

OBJECTIVES

Cellulitis is a common skin infection resulting in inflammation that may take weeks to resolve despite appropriate antibiotics. It is unclear whether the adjunctive use of nonsteroidal anti-inflammatory drugs hastens the resolution of inflammation in patients with cellulitis.

METHODS

We conducted a double-blind, randomized controlled trial comparing ibuprofen 400 mg three times daily for 5 days with identical placebo in adults with uncomplicated cellulitis of the upper or lower limb who were treated with intravenous cefazolin via an outpatient parenteral antibiotic treatment service at one of two Australian hospitals. Participants were assessed twice daily by a study nurse. The primary outcome measure was the proportion of patients with regression of inflammation 48 hours after the first effective dose of parenteral antibiotics (trial registration ANZCTR 12611000515998).

RESULTS

Fifty-one patients were enrolled; 48 had sufficient data available to be included in the modified intention-to-treat analysis. Inflammation had begun to regress at 48 hours in 20 participants (80%) in the ibuprofen group compared to 15 (65%) in the placebo group (absolute risk difference +15%; 95% confidence interval -10 to +40; p >0.05). There was no significant difference in any secondary outcome. Ibuprofen appeared safe, with no patients developing renal impairment or necrotizing fasciitis.

CONCLUSIONS

This trial demonstrated no significant benefit of adjunctive ibuprofen in adults with uncomplicated cellulitis. The trial was powered to detect a large effect, and hence it is unclear whether the 15% absolute increase in the primary end point in the ibuprofen group was attributable to chance.

Persuasive Reminders for Health Self-Management

Health reminders are integral to self-managing chronic illness. However, to act on these health reminders, patients face many challenges, such as lack of motivation and ability to perform health tasks. As a result, patients experience negative consequences for their health. To investigate the design of health reminders that persuade patients to take action, we conducted six participatory design sessions with two cohorts: mothers of children with asthma, and older adults with type 2 diabetes. Participants used collages, storyboards, and photos to express design ideas for future health reminder systems. From their design artifacts, we identified four types of persuasive reminders for health self-management: introspective, socially supportive, adaptive, and symbolic. We contribute insights into desired features for persuasive reminder systems from the perspectives of patients and informal caregivers, including features that support users to understand why and how to complete health tasks ahead of time, and affordances for intra-familial and patient-provider collaboration.

PD-atricians: Leveraging Physicians and Participatory Design to Develop Novel Clinical Information Tools

Participatory design, a method by which system users and stakeholders meaningfully contribute to the development of a new process or technology, has great potential to revolutionize healthcare technology, yet has seen limited adoption. We conducted a design session with eleven physicians working to create a novel clinical information tool utilizing participatory design methods. During the two-hour session, the physicians quickly engaged in the process and generated a large quantity of information, informing the design of a future tool. By utilizing facilitators experienced in design methodology, with detailed domain expertise, and well integrated into the healthcare organization, the participatory design session engaged a group of users who are often disenfranchised with existing processes as well as health information technology in general. We provide insight into why participatory design works with clinicians and provide guiding principles for how to implement these methods in healthcare organizations interested in advancing health information technology.

Integrating the patient portal into the health management work ecosystem: user acceptance of a novel prototype

People with a chronic illness must manage a myriad of tasks to support their health. Online patient portals can provide vital information and support in managing health tasks through notification and reminder features. However, little is known about the efficacy of these features in managing health tasks via the portal. To elicit feedback about reminder and notification features in patient portals, we employed a patient-centered approach to design new features for managing health tasks within an existing portal tool. We tested three iteratively designed prototypes with 19 patients and caregivers. Our findings provide insights into users' attitudes, behavior, and motivations in portal use. Design implications based on these insights include: (1) building on positive aspects of clinician relationships to enhance engagement with the portal; (2) using face-to-face visits to promote clinician collaboration in portal use; and (3) allowing customization of portal modules to support tasks based on user roles.

"Scared to go to the Hospital": Inpatient Experiences with Undesirable Events

Involving patients in healthcare safety practices has long been an area of priority and importance. However, we still need to understand how patients perceive undesirable events during their hospital stay, and what role patients play in the prevention of these events. To address this gap, we surveyed pediatric inpatients and caregivers to understand their perspectives on undesirable events. By giving them an opportunity to use their own words to describe their experiences, we found a diverse array of undesirable events. Our qualitative analysis revealed four major types of events that patients and caregivers experienced: mismanagement, communication, policy, and lack of care coordination. We also examined the information needs that patients and caregivers experienced during these situations, and learned how they would prefer to receive this information. Based on these results, we provide recommendations for inpatient technologies that could enable patients to identify and prevent such undesirable events.

Bursting the Information Bubble: Identifying Opportunities for Pediatric Patient-Centered Technology

Although hospital care is carefully documented and that information is electronically available to clinicians, few information systems exist for patients and their families to use while they are in the hospital. Information often appears trapped within the hospital room. In this paper, we present findings from three participatory design sessions that we conducted with former patients, their parents, and clinicians from a large children's hospital. Participants discussed challenges they faced getting information while in the hospital, and then designed possible technological solutions. Participants designed technologies aimed at extending parents' access to and involvement in patients' care. Their designs showed opportunities for health informatics within and beyond the children's hospital room: to allow parents and children to disseminate information from within, access information from the hospital room remotely, establish pervasive and collaborative communication with the clinical care team, and learn about their child's care throughout the hospital stay.

"How Did We Get Here?": Topic Drift in Online Health Discussions

Background

Patients increasingly use online health communities to exchange health information and peer support. During the progression of health discussions, a change of topic—topic drift—can occur. Topic drift is a frequent phenomenon linked to incoherence and frustration in online communities and other forms of computer-mediated communication. For sensitive topics, such as health, such drift could have life-altering repercussions, yet topic drift has not been studied in these contexts.

Objective

Our goals were to understand topic drift in online health communities and then to develop and evaluate an automated approach to detect both topic drift and efforts of community members to counteract such drift.

Methods

We manually analyzed 721 posts from 184 threads from 7 online health communities within WebMD to understand topic drift, members’ reaction towards topic drift, and their efforts to counteract topic drift. Then, we developed an automated approach to detect topic drift and counteraction efforts. We detected topic drift by calculating cosine similarity between 229,156 posts from 37,805 threads and measuring change of cosine similarity scores from the threads’ first posts to their sequential posts. Using a similar approach, we detected counteractions to topic drift in threads by focusing on the irregular increase of similarity scores compared to the previous post in threads. Finally, we evaluated the performance of our automated approaches to detect topic drift and counteracting efforts by using a manually developed gold standard.

Results

Our qualitative analyses revealed that in threads of online health communities, topics change gradually, but usually stay within the global frame of topics for the specific community. Members showed frustration when topic drift occurred in the middle of threads but reacted positively to off-topic stories shared as separate threads. Although all types of members helped to counteract topic drift, original posters provided the most effort to keep threads on topic. Cosine similarity scores show promise for automatically detecting topical changes in online health discussions. In our manual evaluation, we achieved an F1 score of .71 and .73 for detecting topic drift and counteracting efforts to stay on topic, respectively.

Conclusions

Our analyses expand our understanding of topic drift in a health context and highlight practical implications, such as promoting off-topic discussions as a function of building rapport in online health communities. Furthermore, the quantitative findings suggest that an automated tool could help detect topic drift, support counteraction efforts to bring the conversation back on topic, and improve communication in these important communities. Findings from this study have the potential to reduce topic drift and improve online health community members’ experience of computer-mediated communication. Improved communication could enhance the personal health management of members who seek essential information and support during times of difficulty.

Closing the Gap: Supporting Patients' Transition to Self-Management after Hospitalization

Patients going home after a hospitalization face many challenges. This transition period exposes patients to unnecessary risks related to inadequate preparation prior to leaving the hospital, potentially leading to errors and patient harm. Although patients engaging in self-management have better health outcomes and increased self-efficacy, little is known about the processes in place to support and develop these skills for patients leaving the hospital. Through qualitative interviews and observations of 28 patients during and after their hospitalizations, we explore the challenges they face transitioning from hospital care to self-management. We identify three key elements in this process: knowledge, resources, and self-efficacy. We describe how both system and individual factors contribute to breakdowns leading to ineffective patient management. This work expands our understanding of the unique challenges faced by patients during this difficult transition and uncovers important design opportunities for supporting crucial yet unmet patient needs.

"Not Just a Receiver": Understanding Patient Behavior in the Hospital Environment

Patient engagement leads to better health outcomes and experiences of health care. However, existing patient engagement systems in the hospital environment focus on the passive receipt of information by patients rather than the active contribution of the patient or caregiver as a partner in their care. Through interviews with hospitalized patients and their caregivers, we identify ways that patients and caregivers actively participate in their care. We describe the different roles patients and caregivers assume in interacting with their hospital care team. We then discuss how systems designed to support patient engagement in the hospital setting can promote active participation and help patients achieve better outcomes.

A patient-centered system in a provider-centered world: challenges of incorporating post-discharge wound data into practice

OBJECTIVE

The proposed Meaningful Use Stage 3 recommendations require healthcare providers to accept patient-generated health data (PGHD) by 2017. Yet, we know little about the tensions that arise in supporting the needs of both patients and providers in this context. We sought to examine these tensions when designing a novel, patient-centered technology - mobile Post-Operative Wound Evaluator (mPOWEr) - that uses PGHD for post-discharge surgical wound monitoring.

MATERIALS AND METHODS

As part of the iterative design process of mPOWEr, we conducted semistructured interviews and think-aloud sessions using mockups with surgical patients and providers. We asked participants how mPOWEr could enhance the current post-discharge process for surgical patients, then used grounded theory to develop themes related to conflicts and agreements between patients and providers.

RESULTS

We identified four areas of agreement: providing contextual metadata, accessible and actionable data presentation, building on existing sociotechnical systems, and process transparency. We identified six areas of conflict, with patients preferring: more flexibility in data input, frequent data transfer, text-based communication, patient input in provider response prioritization, timely and reliable provider responses, and definitive diagnoses.

DISCUSSION

We present design implications and potential solutions to the identified conflicts for each theme, illustrated using our work on mPOWEr. Our experience highlights the importance of bringing a variety of stakeholders, including patients, into the design process for PGHD applications.

CONCLUSION

We have identified critical barriers to integrating PGHD into clinical care and describe design implications to help address these barriers. Our work informs future efforts to ensure the smooth integration of essential PGHD into clinical practice.

Partners in Care: Design Considerations for Caregivers and Patients During a Hospital Stay

Informal caregivers, such as close friends and family, play an important role in a hospital patient's care. Although CSCW researchers have shown the potential for social computing technologies to help patients and their caregivers manage chronic conditions and support health behavior change, few studies focus on caregivers' role during a multi-day hospital stay. To explore this space, we conducted an interview and observation study of patients and caregivers in the inpatient setting. In this paper, we describe how caregivers and patients coordinate and collaborate to manage patients' care and wellbeing during a hospital stay. We define and describe five roles caregivers adopt: companion, assistant, representative, navigator, and planner, and show how patients and caregivers negotiate these roles and responsibilities throughout a hospital stay. Finally, we identify key design considerations for technology to support patients and caregivers during a hospital stay.

Leveraging cues from person-generated health data for peer matching in online communities

OBJECTIVE

Online health communities offer a diverse peer support base, yet users can struggle to identify suitable peer mentors as these communities grow. To facilitate mentoring connections, we designed a peer-matching system that automatically profiles and recommends peer mentors to mentees based on person-generated health data (PGHD). This study examined the profile characteristics that mentees value when choosing a peer mentor.

MATERIALS AND METHODS

Through a mixed-methods user study, in which cancer patients and caregivers evaluated peer mentor recommendations, we examined the relative importance of four possible profile elements: health interests, language style, demographics, and sample posts. Playing the role of mentees, the study participants ranked mentors, then rated both the likelihood that they would hypothetically contact each mentor and the helpfulness of each profile element in helping the make that decision. We analyzed the participants' ratings with linear regression and qualitatively analyzed participants' feedback for emerging themes about choosing mentors and improving profile design.

RESULTS

Of the four profile elements, only sample posts were a significant predictor for the likelihood of a mentee contacting a mentor. Communication cues embedded in posts were critical for helping the participants choose a compatible mentor. Qualitative themes offer insight into the interpersonal characteristics that mentees sought in peer mentors, including being knowledgeable, sociable, and articulate. Additionally, the participants emphasized the need for streamlined profiles that minimize the time required to choose a mentor.

CONCLUSION

Peer-matching systems in online health communities offer a promising approach for leveraging PGHD to connect patients. Our findings point to interpersonal communication cues embedded in PGHD that could prove critical for building mentoring relationships among the growing membership of online health communities.