Evaluating the Digital Health Experience for Patients in Primary Care: Mixed Methods Study

BACKGROUND

The digital health divide for socioeconomic disadvantage describes a pattern in which patients considered socioeconomically disadvantaged, who are already marginalized through reduced access to face-to-face health care, are additionally hindered through less access to patient-initiated digital health. A comprehensive understanding of how patients with socioeconomic disadvantage access and experience digital health is essential for improving the digital health divide. Primary care patients, especially those with chronic disease, have experience of the stages of initial help seeking and self-management of their health, which renders them a key demographic for research on patient-initiated digital health access.

OBJECTIVE

This study aims to provide comprehensive primary mixed methods data on the patient experience of barriers to digital health access, with a focus on the digital health divide.

METHODS

We applied an exploratory mixed methods design to ensure that our survey was primarily shaped by the experiences of our interviewees. First, we qualitatively explored the experience of digital health for 19 patients with socioeconomic disadvantage and chronic disease and second, we quantitatively measured some of these findings by designing and administering a survey to 487 Australian general practice patients from 24 general practices.

RESULTS

In our qualitative first phase, the key barriers found to accessing digital health included (1) strong patient preference for human-based health services; (2) low trust in digital health services; (3) high financial costs of necessary tools, maintenance, and repairs; (4) poor publicly available internet access options; (5) reduced capacity to engage due to increased life pressures; and (6) low self-efficacy and confidence in using digital health. In our quantitative second phase, 31% (151/487) of the survey participants were found to have never used a form of digital health, while 10.7% (52/487) were low- to medium-frequency users and 48.5% (236/487) were high-frequency users. High-frequency users were more likely to be interested in digital health and had higher self-efficacy. Low-frequency users were more likely to report difficulty affording the financial costs needed for digital access.

CONCLUSIONS

While general digital interest, financial cost, and digital health literacy and empowerment are clear factors in digital health access in a broad primary care population, the digital health divide is also facilitated in part by a stepped series of complex and cumulative barriers. Genuinely improving digital health access for 1 cohort or even 1 person requires a series of multiple different interventions tailored to specific sequential barriers. Within primary care, patient-centered care that continues to recognize the complex individual needs of, and barriers facing, each patient should be part of addressing the digital health divide.

In Vitro and In Vivo Testing of Microbe Growth on Antimicrobial Nursing Scrubs

Around 5% to 10% of hospitalized patients develop a hospital-acquired infection (HAI). Scrubs are a potential vector of HAIs. To compare the antimicrobial characteristics of scrubs with and without an antimicrobial fabric coating, as tested in the laboratory (in vitro) and hospital (in vivo) environments. Two protocols were conducted to address the purpose. The in vitro protocol was a laboratory study that involved observing the microbe growth after inoculating coated and uncoated scrub fabric swatches with S. aureus and then processing them in moist and dry environments. The in vivo protocol was a clinical trial that measured microbe growth on coated and uncoated scrubs prior to and following nursing staff completing a 12-hr shift on an acute care unit, as measured by colony forming units (CFUs). For high-humidity environments, the in vitro study indicated that swatches treated with an antimicrobial coating exhibited minimal microbe growth, while untreated swatches exhibited significant microbe growth. For low-humidity environments, coated and uncoated swatches were all found to exhibit minimal microbe growth. In the in vivo study, the CFUs increased on scrubs worn by nurses over a 12-hr shift with no significant difference in CFUs for coated and uncoated scrubs. For bacteria in a warm and moist environment, the antimicrobial coating was found to be important for inhibiting growth. For bacteria in a warm and dry environment, both coated and uncoated fabrics performed similarly as measured at 24 hr, with minimal bacterial growth observed. In a hospital environment, microbe growth was observed, but no significant difference was detected when comparing coated and uncoated scrubs. This may have been due to the short time between exposure and culturing the scrubs for analysis immediately at the end of the shift not allowing for enough time to kill or inhibit growth. Contact time between the bacteria and scrub fabric (coated or uncoated) in the in vivo study more directly correlated with the 0-hr observations for the in vitro study, suggesting that the ineffectiveness of the treated scrubs in the clinical results may be due in part to short residence times before collection.

HTA community perspectives on the use of patient preference information: lessons learned from a survey with members of HTA bodies

This research sought to assess whether and how patient preference (PP) data are currently used within health technology assessment (HTA) bodies and affiliated organizations involved in technology/drug appraisals and assessments. An exploratory survey was developed by the PP Project Subcommittee of the HTA International Patient and Citizen Involvement Interest Group to gain insight into the use, impact, and role of PP data in HTA, as well as the perceived barriers to its incorporation. Forty members of HTA bodies and affiliated organizations from twelve countries completed the online survey. PP data were reported to be formally considered as part of the HTA evidence review process by 82.5 percent of the respondents, while 39.4 percent reported that most of the appraisals and assessments within their organization in the past year had submitted PP data. The leading reason for why PP data were not submitted in most assessments was time/resource constraints followed by lack of clarity on PP data impact. Participants reported that PP data had a moderate level of influence on the deliberative process and outcome of the decision, but a higher level of influence on the decision's quality. Most (81.8 percent) felt patient advocacy groups should be primarily responsible for generating and submitting this type of evidence. Insights from the survey confirm the use of PP data in HTA but reveal barriers to its broader and more meaningful integration. Encouragingly, participants believe obstacles can be overcome, paving the way for a second phase of research involving in-depth collaborative workshops with HTA representatives.

Toward the Implementation of a Value Framework for Diagnostic Technologies: Operationalization, Piloting, and Validation in Latin America

OBJECTIVES

In 2020, a group of 30 stakeholders from Latin America established 15 criteria for a diagnostic technologies value framework (D-VF) to help assess and inform decisions on diagnostic technologies. This article aims to present the operationalization, piloting, and initial validation of the framework for its implementation.

METHODS

This work was carried out collaboratively with a variety of stakeholders. Three sequential phases were undertaken: (1) operationalization of the D-VF through a literature search for conceptual definitions and assessment tools, (2) piloting of the D-VF through a rapid health technology assessment document applying the methodology of the framework, and (3) a face validation process conducted through a virtual workshop, where usefulness and implementation aspects of the framework were assessed.

RESULTS

The operationalization of the framework was conducted, and a methodological user guide was published. The D-VF criteria were applied in a health technology assessment document on human papilloma virus testing in cervical cancer screening. Also, an open-access training program was developed. Stakeholders agreed on the usefulness of the D-VF for assessment and decision-making stages of diagnostic technologies. However, they highlighted the need to improve technical capacities and the potential for added complexity when applying a D-VF with many criteria. The absence of an established value framework for diagnostic technologies in Latin America and the potential for strengthening technical capacities made the project valuable to those involved.

CONCLUSIONS

The diagnostic technologies value framework was shown to be fit for implementation in real-life decision-making settings after the operationalization, piloting, and initial validation phases. Further experiences are important to support its implementation.

Learnings From Implementation of Technology-Enabled Mental Health Interventions in India: Implementation Report

BACKGROUND

Recent years have witnessed an increase in the use of technology-enabled interventions for delivering mental health care in different settings. Technological solutions have been advocated to increase access to care, especially in primary health care settings in low- and middle-income countries, to facilitate task-sharing given the lack of trained mental health professionals.

OBJECTIVE

This report describes the experiences and challenges faced during the development and implementation of technology-enabled interventions for mental health among adults and adolescents in rural and urban settings of India.

METHODS

A detailed overview of the technological frameworks used in various studies, including the Systematic Medical Appraisal and Referral Treatment (SMART) Mental Health pilot study, SMART Mental Health cluster randomized controlled trial, and Adolescents' Resilience and Treatment Needs for Mental Health in Indian Slums (ARTEMIS) study, is provided. This includes the mobile apps that were used to collect data and the use of the database to store the data that were collected. Based on the experiences faced, the technological enhancements and adaptations made at the mobile app and database levels are described in detail.

IMPLEMENTATION (RESULTS)

Development of descriptive analytics at the database level; enabling offline and online data storage modalities; customizing the Open Medical Record System platform to suit the study requirements; modifying the encryption settings, thereby making the system more secure; and merging different apps for simultaneous data collection were some of the enhancements made across different projects.

CONCLUSIONS

Technology-enabled interventions prove to be a useful solution to cater to large populations in low-resource settings. The development of mobile apps is subject to the context and the area where they would be implemented. This paper outlines the need for careful testing using an iterative process that may support future research using similar technology.

TRIAL REGISTRATION

SMART Mental Health trial: Clinical Trial Registry India CTRI/2018/08/015355; https://ctri.nic.in/Clinicaltrials/pmaindet2.php?EncHid=MjMyNTQ=&Enc=&userName=CTRI/2018/08/015355. ARTEMIS trial: Clinical Trial Registry India CTRI/2022/02/040307; https://ctri.nic.in/Clinicaltrials/pmaindet2.php?EncHid=NDcxMTE=&Enc=&userName=CTRI/2022/02/040307.

Integrated Devices: A New Regulatory Pathway to Promote Revolutionary Innovation

Policy Points Current medical device regulatory frameworks date back half a century and are ill suited for the next generation of medical devices that involve a significant software component. Existing Food and Drug Administration efforts are insufficient because of a lack of statutory authority, whereas international examples offer lessons for improving and harmonizing domestic medical device regulatory policy. A voluntary alternative pathway built upon two-stage review with individual component review followed by holistic review for integrated devices would provide regulators with new tools to address a changing medical device marketplace.

Quantifying Induced Nystagmus Using a Smartphone Eye Tracking Application (EyePhone)

BACKGROUND

There are ≈5 million annual dizziness visits to US emergency departments, of which vestibular strokes account for over 250 000. The head impulse, nystagmus, and test of skew eye examination can accurately distinguish vestibular strokes from peripheral dizziness. However, the eye-movement signs are subtle, and lack of familiarity and difficulty with recognition of abnormal eye movements are significant barriers to widespread emergency department use. To break this barrier, we sought to assess the accuracy of EyePhone, our smartphone eye-tracking application, for quantifying nystagmus.

METHODS AND RESULTS

We prospectively enrolled healthy volunteers and recorded the velocity of induced nystagmus using a smartphone eye-tracking application (EyePhone) and then compared the results with video oculography (VOG). Following a calibration protocol, the participants viewed optokinetic stimuli with incremental velocities (2-12 degrees/s) in 4 directions. We extracted slow phase velocities from EyePhone data in each direction and compared them with the corresponding slow phase velocities obtained by the VOG. Furthermore, we calculated the area under the receiver operating characteristic curve for nystagmus detection by EyePhone. We enrolled 10 volunteers (90% men) with an average age of 30.2±6 years. EyePhone-recorded slow phase velocities highly correlated with the VOG recordings (r=0.98 for horizontal and r=0.94 for vertical). The calibration significantly increased the slope of linear regression for horizontal and vertical slow phase velocities. Evaluating the EyePhone's performance using VOG data with a 2 degrees/s threshold showed an area under the receiver operating characteristic curve of 0.87 for horizontal and vertical nystagmus detection.

CONCLUSIONS

We demonstrated that EyePhone could accurately detect and quantify optokinetic nystagmus, similar to the VOG goggles.

Rationale and Design of the mTECH-Rehab Randomized Controlled Trial: Impact of a Mobile Technology Enabled Corrie Cardiac Rehabilitation Program on Functional Status and Cardiovascular Health

BACKGROUND

Cardiac rehabilitation (CR) is an evidence-based, guideline-recommended intervention for patients recovering from a cardiac event, surgery or procedure that improves morbidity, mortality, and functional status. CR is traditionally provided in-center, which limits access and engagement, most notably among underrepresented racial and ethnic groups due to barriers including cost, scheduling, and transportation access. This study is designed to evaluate the Corrie Hybrid CR, a technology-based, multicomponent health equity-focused intervention as an alternative to traditional in-center CR among patients recovering from a cardiac event, surgery, or procedure compared with usual care alone.

METHODS

The mTECH-Rehab (Impact of a Mobile Technology Enabled Corrie CR Program) trial will randomize 200 patients who either have diagnosis of myocardial infarction or who undergo coronary artery bypass grafting surgery, percutaneous coronary intervention, heart valve repair, or replacement presenting to 4 hospitals in a large academic health system in Maryland, United States, to the Corrie Hybrid CR program combined with usual care CR (intervention group) or usual care CR alone (control group) in a parallel arm, randomized controlled trial. The Corrie Hybrid CR program leverages 5 components: (1) a patient-facing mobile application that encourages behavior change, patient empowerment, and engagement with guideline-directed therapy; (2) Food and Drug Administration-approved smart devices that collect health metrics; (3) 2 upfront in-center CR sessions to facilitate personalization, self-efficacy, and evaluation for the safety of home exercise, followed by a combination of in-center and home-based sessions per participant preference; (4) a clinician dashboard to track health data; and (5) weekly virtual coaching sessions delivered over 12 weeks for education, encouragement, and risk factor modification. The primary outcome is the mean difference between the intervention versus control groups in distance walked on the 6-minute walk test (ie, functional capacity) at 12 weeks post randomization. Key secondary and exploratory outcomes include improvement in a composite cardiovascular health metric, CR engagement, quality of life, health factors (including low-density lipoprotein-cholesterol, hemoglobin A1c, weight, diet, smoking cessation, blood pressure), and psychosocial factors. Approval for the study was granted by the local institutional review board. Results of the trial will be published once data collection and analysis have been completed.

CONCLUSIONS

The Corrie Hybrid CR program has the potential to improve functional status, cardiovascular health, and CR engagement and advance equity in access to cardiac rehabilitation.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT05238103.

Using science as a differentiator in a crowded digital mental health market

The digital mental health industry has seen remarkable growth in recent years. However, within this crowded landscape, many companies overlook a critical factor for gaining a competitive edge: the integration of science. In this context, "science" refers to the strategic collection and analysis of information (i.e., data) at digital mental health companies, aimed at guiding business decisions and achieving business objectives. This paper demonstrates that science is integral, yet underutilized in the digital mental health industry, with common misconceptions about its role. When science is integrated within a company, it enables them to (1) innovate, (2) understand customers, (3) make informed decisions, and (4) drive revenue. Digital mental health companies recognizing the multifaceted value of science may be better equipped for sustainable growth and success amid the crowded digital health market.

Experiences of health and social professionals using care technologies with older adults during the COVID-19 pandemic: A qualitative study

OBJECTIVE

To investigate the perceptions and experiences of health and social care professionals concerning the use of technology for the care of older adults during the COVID-19 pandemic.

DESIGN AND MEASURES

A phenomenological qualitative, exploratory, and descriptive design using semi-structured interviews.

SAMPLE

Twenty Spanish health and social care workers in six Spanish cities between February and July 2021, during the COVID-19 pandemic.

RESULTS

During the COVID-19 pandemic care workers have become more familiar with technology devices, but they also recognize certain barriers for the implementation of technology, mainly in nursing homes and homecare, related to concerns of lack of humanization and difficulties in accessing and using these devices.

CONCLUSION

Politicians and social and healthcare managers should be aware of the benefits of techno-care, reducing the difficulties in implementing it and making more funding and further training available to care providers.

Haptic Nudging Using a Wearable Device to Promote Upper Limb Activity during Stroke Rehabilitation: Exploring Diurnal Variation, Repetition, and Duration of Effect

Haptic nudging via wearable devices promotes physical activity and may increase upper limb movement in stroke rehabilitation. This study investigated the optimal approach to haptic nudging by examining diurnal variation, duration of effect, and repeated nudging. The study analysed data from a multiple-period randomised crossover study. A 12 h inpatient rehabilitation day was divided into 72 intervals in which participants with stroke (n = 20) randomly received either a 'nudge' or 'no nudge'. Upper limb movement was observed, classified, and analysed using longitudinal mixed models. The odds of affected upper limb movement following a nudge compared with no nudge were significantly higher during active periods such as breakfast, lunch, and morning and afternoon activities (odds ratios (ORs) 2.01-4.63, 95% CIs [1.27-2.67, 3.17-8.01]), but not dinner (OR 1.36, 95% CI [0.86, 2.16]). The effect of nudging was no longer statistically significant at 50-60 s post-nudge. Consecutive delays in nudging significantly decreased the odds of moving when a nudge was eventually delivered. Contrary to expectations, people with stroke appear more responsive to haptic nudging during active periods rather than periods of inactivity. By understanding the optimal timing and frequency of haptic nudging, the design of wearable devices can be optimised to maximise their therapeutic benefits.

Emerging Health Technologies in Long-Term Care and Suppliers' Views on Their Potential to Assist and Support the Workforce

Emerging technological advances hold potential to assist the long-term care (LTC) workforce in caring for an aging population in the home and LTC settings. Technology may alter workforce needs and mitigate rising workforce demand. This study identified and assessed emerging technologies that may assist, replace, and/or support recruitment and retention of the LTC workforce and identified barriers and facilitators to their implementation. We identified a variety of technologies with applications for LTC, created a taxonomy of technology types and functions across LTC settings, and conducted semi-structured interviews with a sample of company leaders to assess perceived impact of their products and services on the LTC workforce. Thematic analysis of those interviews found that technology is not currently positioned to replace the LTC workforce but may facilitate work and support worker recruitment and retention. More rigorous evaluation of technologies in LTC and financing mechanisms are needed to support widespread adoption.

Patient and Physician Perspectives on the Use of a Connected Ecosystem for Diabetes Management: International Cross-Sectional Observational Study

BACKGROUND

Collaboration between people with type 2 diabetes (T2DM) and their health care teams is important for optimal control of the disease and outcomes. Digital technologies could potentially tie together several health care-related devices and platforms into connected ecosystems (CES), but attitudes about CES are unknown.

OBJECTIVE

We surveyed convenience samples of patients and physicians to better understand which patient characteristics are associated with higher likelihoods of (1) participating in a potential CES program, as self-reported by patients with T2DM and (2) clinical benefit from participation in a potential CES program, as reported by physicians.

METHODS

Adults self-reporting a diagnosis of T2DM and current insulin use (n=197), and 33 physicians whose practices included ≥20% of such patients, were enrolled in the United States, France, and Germany. We surveyed both groups about the likelihood of patient participation in a CES. We then examined the associations between patients' clinical and sociodemographic characteristics and this likelihood. We also described characteristics of patients likely to clinically benefit from CES use, according to physicians.

RESULTS

Compared with patients in Germany and France, US patients were younger (mean age 45.3 [SD 11.9] years vs 61.9 [SD 9.2] and 65.8 [SD 9.4] years, respectively), more often female, more highly educated, and more often working full-time. In all, 51 (44.7%) US patients, 16 (36.4%) German patients, and 18 (46.3%) French patients indicated strong interest in a CES program, and 115 (78.7%) reported currently using ≥1 connected device or app. However, physicians believed that only 11.3%-19.2% of their patients were using connected devices or apps to manage their disease. Physicians also reported infrequently recommending or prescribing connected devices to their patients, although ≥80% (n=28) of them thought that a CES could help support their patients in managing their disease. The factors most predictive of patient likelihood of participating in a CES program were cost, inclusion of medication reminders, and linking blood glucose levels to behaviors such as eating and exercise. In all countries, the most common patient expectations for a CES program were that it could help them eat more healthfully, increase their physical activity, increase their understanding of how blood glucose relates to behavior such as exercise and eating, and reduce stress. Physicians thought that newly diagnosed patients, sicker patients-those who had been hospitalized for diabetes, were currently using insulin, or who had any comorbid condition-and patients who were nonadherent to treatment were most likely to benefit from CES use.

CONCLUSIONS

In this study, there was a high degree of interest in the future use of CES, although additional education is needed among both patients with T2DM and their physicians to achieve the full potential of such systems to improve self-management and clinical care for the disease.

Moving from intervention management to disease management: a qualitative study exploring a systems approach to health technology assessment in Canada

OBJECTIVES

Health technology assessment (HTA) traditionally informs decision making for single health technologies, which could lead to ill-informed decisions, suboptimal care, and system inefficiencies. We explored opportunities for conceptualizing the decision space in HTA as a disease management question versus an intervention management question.

METHODS

Semistructured interviews were conducted between April 2022 and October 2022 with purposefully selected individuals from national and provincial HTA agencies and related organizations in Canada. We conducted manual line by line coding of data informed by our interview guide and sensitizing concepts from the literature. One author coded the data, and findings were independently verified by a second author who coded a subset of transcripts.

RESULTS

Twenty-four invitations were distributed, and eighteen individuals agreed to participate. A disease management approach to HTA was differentiated from traditional approaches as being disease-based, multi-interventional, and dynamic. There was general support for an explicit care pathway approach to HTA by informing discussions around patient choice and suboptimal care, creating a space where decision makers can collaborate on shared objectives, and in setting up a platform for open dialogue about managing high-cost and high-severity diseases. There are opportunities for a care pathway approach to be implemented that build on the strengths of the existing HTA system in Canada.

CONCLUSIONS

A disease management approach may enhance the impact of HTA by supporting dynamic decision making that could better inform a proactive, resilient, and sustainable healthcare system in Canada.

eHealth Tools Supporting Early Childhood Education and Care Centers to Assess and Enhance Nutrition and Physical Activity Environments: Protocol for a Scoping Review

BACKGROUND

Many children today are growing up in environments that predispose them to develop noncommunicable diseases. While no single preventive solution exists, evidence supports interventions in childcare settings for establishing good nutrition and physical activity behaviors as a "critical window" that could reduce the risk of developing noncommunicable diseases later in life. Emerging eHealth tools have shown potential in promoting best practices for nutrition and physical activity environments in early childhood education and care (ECEC) settings.

OBJECTIVE

The primary objective of this review is to map the breadth of available evidence on eHealth tools currently available to assess and support best practices for nutrition, physical activity, or both in ECEC settings and to highlight potential research directions.

METHODS

This scoping review will be conducted in accordance with the Joanna Briggs Institute Manual for Scoping Reviews with adherence to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) checklist guidelines. Eligibility is based on the Population, Concept, and Context criteria as follows: (1) early childhood educators (population); (2) eHealth (digital) technology, such as websites, smartphone apps, email, and social media (concept); and (3) measurement and intervention tools to support best practices for nutrition, physical activity, or both in ECEC settings (context). The information sources for this review are the bibliographic databases PubMed, Scopus, CINAHL Plus, ERIC, and Embase in English and French with no date restrictions. Following this, a scan of gray literature will be undertaken. The electronic search strategy was developed in collaboration with two librarians. Two independent reviewers will screen the titles and abstracts of all relevant publications against inclusion criteria, followed by a full-text review using a data extraction tool developed by the reviewers. A synthesis of included papers will describe the publication, assessment, and intervention tool details. A summary of the findings will describe the types of eHealth assessment tools available, psychometric properties, eHealth intervention components, and theoretical frameworks used for development.

RESULTS

Preliminary searches of bibliographic databases to test and calibrate the search were carried out in May 2023. Study selection based on titles and abstracts was started in August 2023. The developed search strategy will guide our search for gray literature. The findings will be presented in visualized data map format, waffle chart, or tabular format accompanied by a narrative discussion. The scoping review is planned for completion in 2024.

CONCLUSIONS

A structured review of the literature will provide a summary of the range and type of eHealth tools available for ECEC programs to assess and improve nutrition environments, physical activity environments, or both in order to identify gaps in the current evidence base and provide insights to guide future intervention research.

TRIAL REGISTRATION

Open Science Framework XTRNZ; https://osf.io/xtrnz.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52252.

Digital Health for Migrants, Ethnic and Cultural Minorities and the Role of Participatory Development: A Scoping Review

Digital health interventions (DHIs) are increasingly used to address the health of migrants and ethnic minorities, some of whom have reduced access to health services and worse health outcomes than majority populations. This study aims to give an overview of digital health interventions developed for ethnic or cultural minority and migrant populations, the health problems they address, their effectiveness at the individual level and the degree of participation of target populations during development. We used the methodological approach of the scoping review outlined by Tricco. We found a total of 2248 studies, of which 57 were included, mostly using mobile health technologies, followed by websites, informational videos, text messages and telehealth. Most interventions focused on illness self-management, mental health and wellbeing, followed by pregnancy and overall lifestyle habits. About half did not involve the target population in development and only a minority involved them consistently. The studies we found indicate that the increased involvement of the target population in the development of digital health tools leads to a greater acceptance of their use.

Smartphone Apps for Containing the COVID-19 Pandemic in Germany: Qualitative Interview Study With Experts Based on Grounded Theory

BACKGROUND

Smartphone apps, including those for digital contact tracing (DCT), played a crucial role in containing infections during the COVID-19 pandemic. Their primary function is to generate and disseminate information to disrupt transmissions based on various events, such as encounters, vaccinations, locations, or infections. Although the functionality of these apps has been extensively studied, there is still a lack of qualitative research addressing critical issues.

OBJECTIVE

We will demonstrate that the use of DCT presents a challenge due to the tension between continuous health monitoring and uncertainties related to transparency and user sovereignty. On one hand, DCT enables the monitoring of various risk factors, including data-based calculations of infection probabilities. On the other hand, continuous risk management is intertwined with several uncertainties, including the unclear storage of personal data, who has access to it, and how it will be used in the future.

METHODS

We focus on the German "Corona-Warn-App" and support our argument with empirical data from 19 expert interviews conducted between 2020 and 2021. The interviews were conducted using a semistructured questionnaire and analyzed according to the principles of grounded theory.

RESULTS

Our data underscores 3 dimensions: transparency, data sovereignty, and the east-west divide. While transparency is considered an essential foundation for establishing trust in the use of DCT by providing a sense of security, data sovereignty is seen as a high value during the pandemic, protecting users from an undesired loss of control. The aspect of the east-west divide highlights the idea of incorporating sociocultural values and standards into technology, emphasizing that algorithms and data-driven elements, such as distance indicators, encounters, and isolations, are also influenced by sociocultural factors.

CONCLUSIONS

The effective use of DCT for pandemic containment relies on achieving a balance between individual control and technological prevention. Maximizing the technological benefits of these tools is crucial. However, users must also be mindful of the information they share and maintain control over their shared data.

Amplifying Older Aboriginal and Torres Strait Islander Women's Perspectives to Promote Digital Health Equity: Co-Designed Qualitative Study

BACKGROUND

Digital health is becoming ubiquitous, and we must ensure equity in access. Indigenous people across most high-income countries typically have not benefited as much as other citizens from usual health care systems and technologies. Despite Aboriginal and Torres Strait Islander people's clear interest in, and enthusiastic use of, new technologies, little research has examined the needs or interests of older Aboriginal and Torres Strait Islander women.

OBJECTIVE

This study prioritizes the perspectives of older Aboriginal and Torres Strait Islander women, tapping into their expertise associated with Indigenous ways of knowing, being, and doing, as well as their unique position within their families and communities, to design a model for using digital technologies to improve health for themselves and their families as well as their communities.

METHODS

Older Aboriginal and Torres Strait Islander women from 4 partner organizations were recruited for this study. This co-designed qualitative research included citizen scientists in shaping the protocol as well as collecting, analyzing, and interpreting data. We used yarning, an Indigenous research method validated for use in health research with Indigenous people and seen as respectful and culturally safe, as a primary research tool. The use of Indigenous methodologies and our iterative process enabled us to deeply explore and incorporate perspectives from all participants and ensure that the perspectives of Indigenous citizen scientists with lived experience were privileged. The data-checking methods also used a yarning methodology, which ensured that the findings and translational model derived from the findings were validated by the participants.

RESULTS

Participants comprised 24 Aboriginal and Torres Strait Islander women aged ≥41 years and including 3 generations that did not grow up with the internet: seniors, baby boomers, and Generation X. The key findings in this research were that older women use various digital technologies to improve health and well-being for themselves and their families as well as their communities. Older Aboriginal women want a culturally sensitive cyberspace that caters specifically to their needs and includes relevant content and functionality that are accessible and efficient. Our translational model highlights the conditions necessary for anyone to use digital health technologies, summarizes the essential elements needed to promote equity in digital health, and illuminates the unmet needs and requirements for older Aboriginal and Torres Strait Islander women to fully benefit from digital health technologies.

CONCLUSIONS

Health is a fundamental right. As we move toward greater reliance on digital health solutions, we must recognize and address the concerns of the smaller populations of people who differ in their needs. We must urgently address the financial, connectivity, and other limiting factors highlighted by older Aboriginal and Torres Strait Islander women in this study that limit equitable access to digital health tools.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1177/20552076221084469.

Closing the loop between horizon scanning and health technology assessment - an overview of topics submitted for appraisal in England

OBJECTIVES

Horizon scanning for health technology appraisal (HTA) in England involves topic notification to the National Institute for Health and Care Excellence (NICE) via technology briefings. This activity is undertaken by the Innovation Observatory with submission timelines designed to ensure that HTA decisions align with regulatory approval time. In this paper, we aimed to track and assess the progression and current status of the topics notified for HTA and provide a descriptive analysis of these topics.

METHODS

Technology briefings were mapped from submission to NICE technology appraisal/highly specialized technologies recommendations from April 2017 until October 2021. This was done using a combination of searches on Google and NICE website, searching a downloadable spreadsheet containing NICE topic selection decisions, and querying NICE Topic Selection team. Analysis was undertaken regarding type of indications and interventions of submitted topics and published guidance.

RESULTS

Six-hundred and ninety-three topics entered the NICE scoping process, of which 94 percent were prioritized. As of November 2021, approximately 39 percent of prioritized topics were in scoping/in progress, 31 percent were proposed/completed, 20 percent were suspended/terminated, and 4 percent were referred back to Innovation Observatory (IO) for further monitoring.

CONCLUSIONS

Our work demonstrates that horizon scanning for HTA is a complex and time-intensive process. Timelines and progress through HTA is challenging due to the growing number of innovative medicines, significant uncertainties, and limited transparency in clinical development and regulatory pathways. A better understanding of clinical trials and regulatory requirements may help eliminate some of this uncertainty and improve timely HTA.

Prototyping Apps for the Management of Sleep, Fatigue, and Behavioral Health in Austere Far-Forward Environments: Development Study

BACKGROUND

Military service inherently includes frequent periods of high-stress training, operational tempo, and sustained deployments to austere far-forward environments. These occupational requirements can contribute to acute and chronic sleep disruption, fatigue, and behavioral health challenges related to acute and chronic stress and disruption of team dynamics. To date, there is no centralized mobile health platform that supports self- and supervised detection, monitoring, and management of sleep and behavioral health issues in garrison and during and after deployments.

OBJECTIVE

The objective of this study was to adapt a clinical decision support platform for use outside clinical settings, in garrison, and during field exercises by medics and soldiers to monitor and manage sleep and behavioral health in operational settings.

METHODS

To adapt an existing clinical decision support digital health platform, we first gathered system, content, and context-related requirements for a sleep and behavioral health management system from experts. Sleep and behavioral health assessments were then adapted for prospective digital data capture. Evidence-based and operationally relevant educational and interventional modules were formatted for digital delivery. These modules addressed the management and mitigation of sleep, circadian challenges, fatigue, stress responses, and team communication. Connectivity protocols were adapted to accommodate the absence of cellular or Wi-Fi access in deployed settings. The resulting apps were then tested in garrison and during 2 separate field exercises.

RESULTS

Based on identified requirements, 2 Android smartphone apps were adapted for self-monitoring and management for soldiers (Soldier app) and team supervision and intervention by medics (Medic app). A total of 246 soldiers, including 28 medics, received training on how to use the apps. Both apps function as expected under conditions of limited connectivity during field exercises. Areas for future technology enhancement were also identified.

CONCLUSIONS

We demonstrated the feasibility of adapting a clinical decision support platform into Android smartphone-based apps to collect, save, and synthesize sleep and behavioral health data, as well as share data using adaptive data transfer protocols when Wi-Fi or cellular data are unavailable. The AIRE (Autonomous Connectivity Independent System for Remote Environments) prototype offers a novel self-management and supervised tool to augment capabilities for prospective monitoring, detection, and intervention for emerging sleep, fatigue, and behavioral health issues that are common in military and nonmilitary high-tempo occupations (eg, submarines, long-haul flights, space stations, and oil rigs) where medical expertise is limited.

Exploring the Perspectives and Experiences of Older Adults With Asthma and Chronic Obstructive Pulmonary Disease Toward Mobile Health: Qualitative Study

BACKGROUND

The use of mobile health (mHealth) in asthma and chronic obstructive pulmonary disease (COPD) is growing, and as the population ages, a greater number of older adults stand to benefit from mHealth-enhanced airway disease care. Though older adults are a heterogeneous population of health technology users, older age represents a potential barrier to health technology adoption, and there is currently a lack of knowledge on how older age influences mHealth use in asthma and COPD.

OBJECTIVE

In this qualitative study, we sought to explore the experiences and perspectives of adults who were aged 65 years and older with asthma and COPD toward mHealth use.

METHODS

Semistructured individual interviews were conducted with adults who were aged 65 years and older with asthma or COPD and owned a smartphone. Applying phenomenological methodology, we analyzed interview transcripts in order to develop themes and propose an essential experience of mHealth use among older adults with airway disease. We then summarized our qualitative findings and proposed strategies to leverage our results in order to guide future research and implementation efforts targeting older adults' use of airway mHealth.

RESULTS

Twenty participants (mean age 79.8, SD 4.4 years) were interviewed. Participants described a central tension between (1) the perception that mHealth could help maintain independence throughout aging and (2) an apprehension toward the ways in which mHealth could negatively affect established health care experiences. Several elements of these 2 themes are absent from previous research focusing on younger adults with asthma and COPD. The individual elements of these 2 themes informed potential strategies to optimize future older adults' use of asthma and COPD mHealth tools.

CONCLUSIONS

Focusing on the perspectives and experiences of older adults with asthma and COPD in their use of mHealth identified novel understandings of health technology use in this important demographic in need of greater care. These lessons were translated into potential strategies that will need to be objectively evaluated in future airway mHealth research, development, and implementation efforts.

Development and Implementation of an Acute Kidney Injury Remote Patient Monitoring Program: Research Letter

Acute kidney injury (AKI) survivors have a dynamic posthospital course which warrants close monitoring. Remote patient monitoring (RPM) could be used to improve quality and efficiency of AKI survivor care.

Objective

The objective of this report was to describe the development and preliminary feasibility of an AKI RPM program launched in October 2021.

Setting

Academic medical center.

Patients

Patients enrolled in the AKI RPM program were those who experienced AKI during a hospitalization and underwent nephrology consultation.

Measurements/Methods

At enrollment, patients were provided with home monitoring technology and underwent weekly laboratory assessments. Nurses evaluated the data daily and adhered to prespecified protocols for management and escalation of care if needed.

Results

Twenty patients were enrolled in AKI RPM in the first 5 months. Median duration of program participation was 36 (31, 40) days. Eight patients (40%) experienced an unplanned readmission, or an emergency department visit, half (N = 4) of which were attributed to AKI and related circumstances. Of the 9 postgraduation survey respondents, all were satisfied with the RPM program and 89% would recommend RPM to other patients with similar health conditions.

Limitations

Acute kidney injury RPM was made possible by the existing infrastructure in our integrated health system and the robust resources available in the Mayo Clinic Center for Digital Health. Such infrastructure may not be universally available which could limit scale and generalizability of such a program.

Conclusions

Remote patient monitoring can offer a unique opportunity to bridge the care transition from hospital to home and increase access to quality care for the AKI survivors.

Underestimated Factors Regarding the Use of Technology in Daily Practice of Long-Term Care: Qualitative Study Among Health Care Professionals

BACKGROUND

Increasing life expectancy is resulting in a growing demand for long-term care; however, there is a shortage of qualified health care professionals (HCPs) to deliver it. If used optimally, technology can provide a solution to this challenge. HCPs play an important role in the use of technology in long-term care. However, technology influences several core aspects of the work that HCPs do, and it is therefore important to have a good understanding of their viewpoint regarding the use of technology in daily practice of long-term care.

OBJECTIVE

The aim of this study was to identify the factors that HCPs consider as relevant for using technology in daily practice of long-term care.

METHODS

In this qualitative study, 11 focus groups were organized with 73 HCPs. The focus group discussions were guided by an innovative game, which was specifically developed for this study. The content of the game was categorized into 4 categories: health care technology and me; health care technology, the patient, and me; health care technology, the organization, and me; and facilitating conditions. The perspectives of HCPs about working with technology were discussed based on this game. The focus groups were recorded and transcribed, followed by an inductive thematic analysis using ATLAS.ti 9x (ATLAS.ti Scientific Software Development GmbH).

RESULTS

Overall, 2 main domain summaries were developed from the data: technology should improve the quality of care and acceptance and use of technology in care. The first factor indicates the need for tailored and personalized care and balance between human contact and technology. The second factor addresses several aspects regarding working with technology such as trusting technology, learning to work with technology, and collaboration with colleagues.

CONCLUSIONS

HCPs are motivated to use technology in daily practice of long-term care when it adds value to the quality of care and there is sufficient trust, expertise, and collaboration with colleagues. Their perspectives need to be considered as they play a crucial part in the successful use of technology, transcending their role as an actor in implementation. On the basis of the findings from this study, we recommend focusing on developing technology for situations where both efficiency and quality of care can be improved; redefining the roles of HCPs and the impact of technology hereon; involving HCPs in the design process of technology to enable them to link it to their daily practice; and creating ambassadors in care teams who are enthusiastic about working with technology and can support and train their colleagues.

Wearable Devices and Nurses' Health: Protocol for an Integrative Review

BACKGROUND

Nurses comprise over half of the global health care workforce, and the nursing care they provide is critical for the global population's health. High patient volumes and increased medical complexity have increased the workload and stress of nurses. As a result, the health of nurses is often negatively impacted. Wearables are used within the health care setting to assess patient outcomes; however, efforts to synthesize the use of wearable devices focusing on nurses' health are limited.

OBJECTIVE

The primary objective of our integrative review is to synthesize available data concerning the utility of wearable devices for evaluating or improving (or both) the health of nurses.

METHODS

We are conducting an integrative review synthesizing data specific to wearable devices and nurses' health. The research question for this review aims to answer how wearable devices are used to evaluate health outcomes among nurses. We searched the following electronic databases from inception until July 2022: PubMed, Embase, CINAHL, Web of Science, IEEE Explore, and AS&T. Titles and abstracts were imported into Covidence software, where citations were screened and duplicates removed. Title and abstract screening has been completed; however, full-text screening has not been started. Further screening is being conducted independently and in duplicate by 2 teams of 2 reviewers each. These reviewers will extract data independently.

RESULTS

Search strategies have been developed, and data were extracted from 6 databases. After the removal of duplicates, we collected 8603 studies for title and abstract screening. Two independent reviewers conducted the title and abstract review, and after resolving conflicts, 277 full-text articles are available for review to determine whether they meet the inclusion criteria.

CONCLUSIONS

This integrative review will provide synthesized data to inform nurses and other stakeholders about the extent of wearable device-related work done with nurses and provide direction for future research.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48178.

Practices of Care in Participatory Design With Older Adults During the COVID-19 Pandemic: Digitally Mediated Study

BACKGROUND

Participatory Design (PD), albeit an established approach in User-Centered Design, comes with specific challenges when working with older adults as research participants. Addressing these challenges relates to the reflection and negotiation of the positionalities of the researchers and research participants and includes various acts of giving and receiving help. During the COVID-19 pandemic, facets of positionalities and (mutual) care became particularly evident in qualitative and participatory research settings.

OBJECTIVE

The aim of this paper was to systematically analyze care practices of participatory (design) research, which are to different extents practices of the latter. Using a multiyear PD project with older people that had to take place remotely over many months, we specify different practices of care; how they relate to collaborative work in the design project; and represent foundational practices for sustainable, long-term co-design. Our research questions were "How can digitally-mediated PD work during COVID-19 and can we understand such digital PD as 'care'?"

METHODS

Our data comes from the Joint Programming Initiative "More Years, Better Lives" (JPI MYBL), a European Union project that aims to promote digital literacy and technology appropriation among older adults in domestic settings. It targeted the cocreation, by older adults and university researchers, of a mobile demo kit website with cocreated resources, aimed at improving the understanding of use options of digital tools. Through a series of workshops, a range of current IT products was explored by a group of 21 older adults, which served as the basis for joint cocreative work on generating design ideas and prototypes. We reflect on the PD process and examine how the actors enact and manifest care.

RESULTS

The use of digital technology allowed the participatory project to continue during the COVID-19 pandemic and accentuated the digital skills of older adults and the improvement of digital literacy as part of "care." We provide empirically based evidence of PD with older adults developing digital literacy and sensitizing concepts, based on the notion of care by Tronto for differentiating aspects and processes of care. The data suggest that it is not enough to focus solely on the technologies and how they are used; it is also necessary to focus on the social structures in which help is available and in which technologies offer opportunities to do care work.

CONCLUSIONS

We document that the cocreation of different digital media tools can be used to provide a community with mutual care. Our study demonstrates how research participants effectively enact different forms of care and how such "care" is a necessary basis for a genuinely participatory approach, which became especially meaningful as a form of support during COVID-19. We reflect on how notions of "care" and "caring" that were central to the pandemic response are also central to PD.

Integration of real-world evidence from different data sources in health technology assessment

Real-world evidence (RWE) is being increasingly used by a wide range of stakeholders involved in the therapeutic product lifecycle but remains underutilized in the health technology assessment (HTA) process. RWE aims to fill the current evidence gaps, reduce the uncertainty around the benefits of medical technologies, and better understand the long-term impact of health technologies in real-world conditions. Despite the minimal use of RWE in some elements of HTA, there has been a larger push to further utilize RWE in the HTA processes. HTA bodies, as other stakeholders, work towards developing more robust means to leverage RWE from various data sources in the HTA processes. However, these agencies need to overcome important challenges before the broader incorporation of RWE into their routine practice. This paper aims to explore the extensive integration of RWE utilizing diverse sources of RWD. We discuss the utilization of RWE in HTA processes, considering aspects such as when, where, and how RWE can be effectively applied. Additionally, we seek the potential challenges and barriers associated with the utilization of different data sources.

Get Smart, Canada: Exploring Smart Pump Implementation, Management, and Compliance with Standards through a Nationwide Survey

Background

Smart pump technology is relatively new, and uncertainty exists regarding best practices for development and management of the drug libraries in these devices. In Canadian hospitals, IV smart pumps and their drug libraries are created and maintained according to recommendations from Accreditation Canada and guidelines from the US Institute for Safe Medication Practices (ISMP). Current compliance with these standards in Canada is unknown. However, neither organization provides specific operational steps detailing how to effectively create and manage a drug library, which leaves significant room for interpretation. Furthermore, the human resources dedicated to creation and management of these libraries in accordance with guidelines and standards are unknown.

Objectives

To describe current compliance with standards and guidelines for smart pump drug libraries; the processes used for drug library set-up, management, training, and support; and the resources currently used for these activities in Canadian hospitals.

Methods

A 43-question online survey was made available in spring 2021 to multidisciplinary team members involved in implementation of IV smart pumps and/or management of drug libraries in Canadian hospitals.

Results

A total of 55 complete or partial responses were received. Most responses indicated that standards set by Accreditation Canada and ISMP were not being met, with only 30% (14/47) updating their libraries at least quarterly and 47% (20/43) performing quality reviews at least every 6 months. Although the majority of respondents reported regular monitoring of compliance, 30% (11/37) did not perform such monitoring. Results further indicated variation across Canadian hospitals in set-up, management, training, and support related to drug libraries, as well as variation in the human resources available for these activities.

Conclusions

Canadian health authorities and organizations are not meeting current ISMP and Accreditation Canada standards for smart pumps. Variation exists in terms of strategies for creating and managing drug libraries, as well as in the training and resources needed to support these initiatives. Canadian health authorities and organizations should prioritize meeting these standards and should closely review the resources required to do so.

Health Wearables, Gamification, and Healthful Activity

Health wearables in combination with gamification enable interventions that have the potential to increase physical activity-a key determinant of health. However, the extant literature does not provide conclusive evidence on the benefits of gamification and there are persistent concerns that competition-based gamification approaches will only benefit those who are highly active at the expense of those who are sedentary. We investigate the effect of Fitbit leaderboards on the number of steps taken by the user. Using a unique dataset of Fitbit wearable users, some of whom participate in a leaderboard, we find that leaderboards lead to a 370 (3.5%) step increase in the users' daily physical activity. However, we find that the benefits of leaderboards are highly heterogeneous. Surprisingly, we find that those who were highly active prior to adoption are hurt by leaderboards and walk 630 fewer steps daily post adoption (a 5% relative decrease). In contrast, those who were sedentary prior to adoption benefited substantially from leaderboards and walked an additional 1,300 steps daily after adoption (a 15% relative increase). We find that these effects emerge because sedentary individuals benefit even when leaderboards are small and when they do not rank first on them. In contrast, highly active individuals are harmed by smaller leaderboards and only see benefit when they rank highly on large leaderboards. We posit that this unexpected divergence in effects could be due to the underappreciated potential of non-competition dynamics (e.g., changes in expectations for exercise) to benefit sedentary users, but harm more active ones.

Human Factors Influencing the Experience of Healthcare Professionals Using Digital Tools

Digitalization in healthcare has the potential to offer numerous advantages to various stakeholders, however, healthcare professionals often encounter difficulties while using digital tools. We conducted a qualitative analysis of published studies to examine the experience of clinicians using digital tools. Our findings revealed that human factors influence clinicians' experiences and that integration of human factors into the design and development of healthcare technologies is of high importance to improve user experience and overall success.

Knowledge, Perceptions and Attitudes of eHealth and Health Technology among Nursing Students from Gauteng Province, South Africa

The use of technology in healthcare settings was identified as a crucial priority in many countries to provide quality healthcare services. eHealth or digital health technology is found to have a positive influence on improving the efficiency and quality of healthcare services. It has been proven to provide opportunities to strengthen health systems. This study aims to assess eHealth literacy, pre-existing knowledge and the nursing students' perceptions and attitudes towards eHealth. A quantitative, descriptive, cross-sectional survey was used in this study. The population of this study comprised 266 nursing students in the undergraduate programme of the Department of Nursing, among which 244 consented to participate in the study. A standardised and self-administered tool was utilised to collect data from nursing students across the four levels of study. Results showed that students in level four exhibit high scores of knowledge in the use of eLearning technology as compared to first-entry university nursing students. Nursing students used the internet frequently, especially to access social media and search for health and medical information for their study. Attitudes towards eHealth and technology were also found to be positive. The study recommends that digital literacy should be enhanced in the nursing education curriculum in other to further strengthen the knowledge and skills towards the use of eHealth and health technology among nursing students.

Development of an eHealth Tool for Capturing and Analyzing the Immune-related Adverse Events (irAEs) in Cancer Treatment

Introduction

Immunotherapy has revolutionized the treatment of many different types of cancer, but it is associated with a myriad of immune-related adverse events (irAEs). Patient-reported outcome (PRO) measures have been identified as valuable tools for continuously collecting patient-centered data and are frequently used in oncology trials. However, few studies still research an ePRO follow-up approach on patients treated with Immunotherapy, potentially reflecting a lack of support services for this population.

Methods

The team co-developed a digital platform (V-Care) using ePROs to create a new follow-up pathway for cancer patients receiving immunotherapy. To operationalize the first 3 phases of the CeHRes roadmap, we employed multiple methods that were integrated throughout the development process, rather than being performed in a linear fashion. The teams employed an agile approach in a dynamic and iterative manner, engaging key stakeholders throughout the process.

Results

The development of the application was categorized into 2 phases: "user interface" (UI) and "user experience" (UX) designs. In the first phase, the pages of the application were segmented into general categories, and feedback from all stakeholders was received and used to modify the application. In phase 2, mock-up pages were developed and sent to the Figma website. Moreover, the Android Package Kit (APK) of the application was installed and tested multiple times on a mobile phone to proactively detect and fix any errors. After resolving some technical issues and adjusting errors on the Android version to improve the user experience, the iOS version of the application was developed.

Discussion

By incorporating the latest technological developments, V-Care has enabled cancer patients to have access to more comprehensive and personalized care, allowing them to better manage their condition and be better informed about their health decisions. These advances have also enabled healthcare professionals to be better equipped with the knowledge and tools to provide more effective and efficient care. In addition, the advances in V-Care technology have allowed patients to connect with their healthcare providers more easily, providing a platform to facilitate communication and collaboration. Although usability testing is necessary to evaluate the efficacy and user experience of the app, it can be a significant investment of time and resources.

Conclusion

The V-Care platform can be used to investigate the reported symptoms experienced by cancer patients receiving Immune checkpoint inhibitors (ICIs) and to compare them with the results from clinical trials. Furthermore, the project will utilize ePRO tools to collect symptoms from patients and provide insight into whether the reported symptoms are linked to the treatment.

Clinical Relevance

V-Care provides a secure, easy-to-use interface for patient-clinician communication and data exchange. Its clinical system stores and manages patient data in a secure environment, while its clinical decision support system helps clinicians make decisions that are more informed, efficient, and cost-effective. This system has the potential to improve patient safety and quality of care, while also helping to reduce healthcare costs.

Progress toward Health System Readiness for Genome-Based Testing in Canada

(1) Background: Genomic medicine harbors the real potential to improve the health and healthcare journey of patients, care provider experiences, and improve the health system efficiency-even reducing healthcare costs. There is expected to be an exponential growth in medically necessary new genome-based tests and test approaches in the coming years. Testing can also create scientific research and commercial opportunities beyond healthcare decision making. The purpose of this research is to generate a better understanding of Canada's state of readiness for genomic medicine, and to provide some insights for other healthcare systems. (2) Methods: A mixed-methods approach of a review of the literature and key informant interviews with a purposive sample of experts was used. The health system readiness was assessed using a previously published set of conditions. (3) Results: Canada has created some of the established conditions, but further action needs to be taken to improve the state of readiness for genome-based medicine. The important gaps to be filled are the need for linked information systems and data integration; evaluative processes that are timely and transparent; navigational tools for care providers; dedicated funding to facilitate rapid onboarding and support test development and proficiency testing; and broader engagement with innovation stakeholders beyond care providers and patients. These findings highlight the role of the organizational context, social influence, and other factors that are known to affect the diffusion of innovation within health systems.

Impact of Technology on Neonatal Intensive Care Unit Admissions and Length of Stay: A Retrospective Study

Background Neonatal intensive care units (NICU) provide essential medical care to neonates; however, they are associated with hospital-acquired infections, less maternal-newborn bonding, and high costs. Implementing strategies to lower NICU admission rates and shorten NICU length of stay (LOS) is essential. This study uses causal-inference methods to evaluate the impact of care managers using new technology to identify and risk stratify pregnancies on NICU admissions and NICU LOS. The NICU LOS will decrease as a result of the use of new technology by care managers. Study design This retrospective study utilized delivery claims data of pregnant women from the CareFirst BlueCross BlueShield Community Health Plan District of Columbia from 2013 to 2022, which includes the pre-intervention period before the use of new technology by care managers and the post-intervention period with the use of new technology by care managers. Our sample had 4,917 deliveries whose maternal comorbidities were matched with their neonate's outcomes. Methods To evaluate the impact of the technological intervention, both Generalized Linear Models (GLMs) and Bayesian Structural Time-Series (BSTS) models were used. Results Our findings from the GLM models suggest an overall average reduction in the odds of NICU admissions of 29.2% and an average decrease in NICU LOS from 7.5%-58.5%. Using BSTS models, we estimate counterfactuals for NICU admissions and NICU LOS, which suggest an average reduction in 48 NICU admissions and 528 NICU days per year. Conclusion Equipping care managers with better technological tools can lead to significant improvements in neonatal health outcomes as indicated by a reduction in NICU admissions and NICU LOS.

A Critical Review of ChatGPT as a Potential Substitute for Diabetes Educators

This review article explores the potential of ChatGPT as a substitute for diabetes educators. Diabetes is a prevalent chronic disease that requires ongoing education and support for patients to effectively manage their condition. However, there is a shortage of diabetes educators, and traditional education methods have limitations in addressing patients' individual needs. ChatGPT is an artificial intelligence technology that offers a personalized and interactive approach to education and support. In this review, we provide an overview of ChatGPT technology, discuss the challenges facing diabetes educators, review evidence supporting the use of ChatGPT in diabetes education, and examine ethical considerations related to its use. We also provide recommendations for further research and development of ChatGPT in diabetes education and integration into clinical practice. ChatGPT has the potential to improve access to education and support for patients with diabetes, but further research is needed to better understand its effectiveness and limitations. It is important to ensure that ChatGPT is developed and integrated in an ethical and equitable manner to maximize its potential benefits and minimize potential risks.

Remote Digital Technologies for the Early Detection and Monitoring of Cognitive Decline in Patients With Type 2 Diabetes: Insights From Studies of Neurodegenerative Diseases

Type 2 diabetes (T2D) is a risk factor for cognitive decline. In neurodegenerative disease research, remote digital cognitive assessments and unobtrusive sensors are gaining traction for their potential to improve early detection and monitoring of cognitive impairment. Given the high prevalence of cognitive impairments in T2D, these digital tools are highly relevant. Further research incorporating remote digital biomarkers of cognition, behavior, and motor functioning may enable comprehensive characterizations of patients with T2D and may ultimately improve clinical care and equitable access to research participation. The aim of this commentary article is to review the feasibility, validity, and limitations of using remote digital cognitive tests and unobtrusive detection methods to identify and monitor cognitive decline in neurodegenerative conditions and apply these insights to patients with T2D.

How Older Indigenous Women Living in High-Income Countries Use Digital Health Technology: Systematic Review

BACKGROUND

Research associated with digital health technologies similar to the technologies themselves has proliferated in the last 2 decades. There are calls for these technologies to provide cost-effective health care for underserved populations. However, the research community has also underserved many of these populations. Older Indigenous women are one such segment of the population.

OBJECTIVE

Our objective is to systematically review the literature to consolidate and document what we know about how older Indigenous women living in high-income countries use digital health technology to enhance their health.

METHODS

We analyzed the peer-reviewed literature by systematically searching 8 databases in March 2022. We included studies published between January 2006 and March 2022 with original data specific to older Indigenous women from high-income countries that reported on the effectiveness, acceptability, and usability of some user-focused digital health technology. We incorporated 2 measures of quality for each study. We also conducted a thematic analysis and a lived experience analysis, which examined each paper from the perspectives of older Indigenous women. We followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines in this study.

RESULTS

Three papers met the inclusion criteria. The key findings were that older Indigenous women do not see themselves reflected in mainstream health messaging or other digital health offerings. They prefer an approach that considers their uniqueness and diversity. We also identified 2 significant gaps in the literature. First, research reporting on older Indigenous women from high-income countries' experiences with digital health technology is minimal. Second, the limited research related to older Indigenous women has not consistently engaged Indigenous people in the research process or governance.

CONCLUSIONS

Older Indigenous women want digital health technologies to respond to their needs and preferences. Research is needed to understand their requirements and preferences to ensure equity as we move toward greater adoption of digital health technology. Engaging older Indigenous women throughout the research is essential to ensuring that digital health products and services are safe, usable, effective, and acceptable for older Indigenous women.

Multilevel Determinants of Digital Health Equity: A Literature Synthesis to Advance the Field

Current digital health approaches have not engaged diverse end users or reduced health or health care inequities, despite their promise to deliver more tailored and personalized support to individuals at the right time and the right place. To achieve digital health equity, we must refocus our attention on the current state of digital health uptake and use across the policy, system, community, individual, and intervention levels. We focus here on (a) outlining a multilevel framework underlying digital health equity; (b) summarizingfive types of interventions/programs (with example studies) that hold promise for advancing digital health equity; and (c) recommending future steps for improving policy, practice, and research in this space.

Understanding public procurement within the health sector: a priority in a post-COVID-19 world

Every year, over 250,000 public authorities in the European Union (EU) spend about 14% of GDP on the purchase of services, works and supplies. Many are in the health sector, a sector in which public authorities are the main buyers in many countries. When these purchases exceed threshold values, EU public procurement rules apply. Public procurement is increasingly being promoted as a tool for improving efficiency and contributing to better health outcomes, and as a policy lever for achieving other government goals, such as innovation, the development of small and medium-sized enterprises, sustainable green growth and social objectives like public health and greater inclusiveness. In this paper, we describe the challenges that arise within health care systems with public procurement and identify potential solutions to them. We examined the tendering of pharmaceuticals, health technology, and e-health. In each case we identify a series of challenges relating to the complexity of the procurement process, imbalances in power on either side of transactions and the role of procurement in promoting broader public policy objectives. Finally, we recommend several actions that could stimulate better procurement, and suggest a few areas where further EU cooperation can be pursued.

Frameworks for Health Technology Assessment at an Early Stage of Product Development: A Review and Roadmap to Guide Applications

OBJECTIVES

Early health technology assessment (eHTA) can be used to evaluate and optimize a medical product's value proposition and to inform go/no-go decisions by using health economic modeling, literature scanning, and stakeholder preference studies at an early stage of development. eHTA frameworks offer high-level guidance on conducting this complex, iterative, and multidisciplinary process. The objective of this study was to review and summarize existing eHTA frameworks, understood as systematic approaches to guide early evidence generation and decision making.

METHODS

Using a rapid review methodology, we identified all relevant studies published in English, French, and Spanish from PubMed/MEDLINE and Embase until February 2022. We only included frameworks relevant to the preclinical and early clinical (phase I) stages of medical product development.

RESULTS

From 737 reviewed abstracts, 53 publications describing 46 frameworks were selected for inclusion and classified into categories based on their scope: (1) criteria frameworks, which provide an overview of eHTA; (2) process frameworks, which offer stepwise guidance for conducting eHTA, including preferred methods; and (3) methods frameworks, which provide detailed descriptions of specific eHTA methods. Most of the frameworks did not specify their target users or the specific stage of technology development.

CONCLUSIONS

Despite some variability and gaps found across existing frameworks, the structure provided by this review helps inform eHTA applications. Remaining challenges are the frameworks' limited accessibility to users without a background in health economics, poor distinctions being made among early lifecycle stages and technology types, and the inconsistent terminology used to describe eHTA in different contexts.

The Use of Digital Health Services Among Patients and Citizens Living at Home: Scoping Review

BACKGROUND

The development of digital health services reflects not only the technical development of services but also a change in attitude and the way of thinking. It has become a cornerstone for engaging and activating patients and citizens in health management while living at home. Digital health services are also aimed at enhancing the efficiency and quality of services, while simultaneously providing services more cost-effectively. In 2020, the COVID-19 pandemic accelerated worldwide the development and use of digital services in response to requirements for social distancing and other regulations.

OBJECTIVE

The aim of this review is to identify and summarize how digital health services are being used among patients and citizens while living at home.

METHODS

The Joanna Briggs Institute (JBI) methodology for scoping reviews was used as guidance. A search conducted in 3 databases (CINAHL, PubMed, Scopus) resulted in 419 papers. The reporting was conducted by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping review (PRISMA-ScR), and the analysis of the included papers was performed using a framework consisting of 5 clusters describing the use of digital health services. After screening and excluding papers that did not match the inclusion criteria, 88 (21%) papers from 2010 to 2022 were included in the final analysis.

RESULTS

Results indicated that digital health services are used in different situations and among different kinds of populations. In most studies, digital health services were used in the form of video visits or consultations. The telephone was also used regularly for consultations. Other services, such as remote monitoring and transmitting of recorded information and the use the of internet or portals for searching information, were observed as well. Alerts, emergency systems, and reminders were observed to offer possibilities of use, for example, among older people. The digital health services also showed to have potential for use in patient education.

CONCLUSIONS

The development of digital services reflects a shift toward the provision of care regardless of time and place. It also reflects a shift toward emphasis on patient-centered care, meaning activating and engaging patients in their own care as they use digital services for various health-related purposes. Despite the development of digital services, many challenges (eg, adequate infrastructure) still prevail worldwide.

Digital Technologies for Health Promotion and Disease Prevention in Older People: Scoping Review

BACKGROUND

Digital technologies have the potential to contribute to health promotion and disease prevention in the aging world.

OBJECTIVE

This study aims to identify digital technologies for health promotion and disease prevention that could be used independently by older people in nonclinical settings using a scoping review.

METHODS

Through database (MEDLINE, PsycINFO, CINAHL, and SCOPUS; to March 3, 2022) and manual searches (to June 14, 2022), 90 primary studies and 8 systematic reviews were included in this scoping review. The eligibility was based on the PCC (Population, Concept, and Context) criteria: (1) people aged 50 years or older (population), (2) any digital (health) technology (eg, smartphone apps, websites, virtual reality; concept), and (3) health promotion and disease prevention in daily life in nonclinical and noninstitutional settings (context). Data items included study characteristics, PCC criteria, opportunities versus challenges, and evidence gaps. Data were synthesized using descriptive statistics or narratively described by identifying common themes.

RESULTS

The studies were published in 2005-2022 and originated predominantly from North America and Europe. Most primary studies were nonrandomized, reported quantitative data, and investigated effectiveness or feasibility (eg, acceptance or usability) of digital technologies in older people. The participants were aged 50 years to 99 years, predominantly female, affluent (ie, with high income, education, and digital competence), and intended to use or used digital technologies for a median of 3 months independently at home or in community settings. The digital technologies included mobile or nonmobile technologies or virtual reality. The studies used "modern devices" (eg, smartphones, wearables, or gaming consoles) or modern and "older devices" (eg, computers or mobile phones). The users interacted with digital technologies via websites, emails, text messages, apps, or virtual reality. Health targets of digital technologies were mobility, mental health, nutrition, or cognition. The opportunities versus challenges of digital technologies were (1) potential health benefits versus unclear or no benefits for some outcomes, (2) monitoring of health versus ethical issues with data collection and management, (3) implications for functioning in daily life (ie, potential to prolong independent living) versus unclear application for clinical management or care, (4) tailoring of technical properties and content toward older users versus general use, (5) importance of human support for feasibility versus other factors required to improve feasibility, (6) reduction of social isolation versus access to digital technologies, and (7) improvement in digital competence versus digital divide.

CONCLUSIONS

Various digital technologies were independently used by people aged 50 years or older for health promotion and disease prevention. Future studies should focus on (1) more diverse populations of older people, (2) new digital technologies, (3) other (clinical and care) settings, and (4) outcome evaluation to identify factors that could enhance any health benefits of digital technologies.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/37729.

A Pilot of Digital Whiteboards for Improving Patient Satisfaction in the Emergency Department: Nonrandomized Controlled Trial

BACKGROUND

Electronic paper (E-paper) screens use electrophoretic ink to provide paper-like low-power displays with advanced networking capabilities that may potentially serve as an alternative to traditional whiteboards and television display screens in hospital settings. E-paper may be leveraged in the emergency department (ED) to facilitate communication. Providing ED patient status updates on E-paper screens could improve patient satisfaction and overall experience and provide more equitable access to their health information.

OBJECTIVE

We aimed to pilot a patient-facing digital whiteboard using E-paper to display relevant orienting and clinical information in real time to ED patients. We also sought to assess patients' satisfaction after our intervention and understand our patients' overall perception of the impact of the digital whiteboards on their stay.

METHODS

We deployed a 41-inch E-paper digital whiteboard in 4 rooms in an urban, tertiary care, and academic ED and enrolled 110 patients to understand and evaluate their experience. Participants completed a modified Hospital Consumer Assessment of Health Care Provider and Systems satisfaction questionnaire about their ED stay. We compared responses to a matched control group of patients triaged to ED rooms without digital whiteboards. We designed the digital whiteboard based on iterative feedback from various departmental stakeholders. After establishing IT infrastructure to support the project, we enrolled patients on a convenience basis into a control and an intervention (digital whiteboard) group. Enrollees were given a baseline survey to evaluate their comfort with technology and an exit survey to evaluate their opinions of the digital whiteboard and overall ED satisfaction. Statistical analysis was performed to compare baseline characteristics as well as satisfaction.

RESULTS

After the successful prototyping and implementation of 4 digital whiteboards, we screened 471 patients for inclusion. We enrolled 110 patients, and 50 patients in each group (control and intervention) completed the study protocol. Age, gender, and racial and ethnic composition were similar between groups. We saw significant increases in satisfaction on postvisit surveys when patients were asked about communication regarding delays (P=.03) and what to do after discharge (P=.02). We found that patients in the intervention group were more likely to recommend the facility to family and friends (P=.04). Additionally, 96% (48/50) stated that they preferred a room with a digital whiteboard, and 70% (35/50) found the intervention "quite a bit" or "extremely" helpful in understanding their ED stay.

CONCLUSIONS

Digital whiteboards are a feasible and acceptable method of displaying patient-facing data in the ED. Our pilot suggested that E-paper screens coupled with relevant, real-time clinical data and packaged together as a digital whiteboard may positively impact patient satisfaction and the perception of the facility during ED visits. Further study is needed to fully understand the impact on patient satisfaction and experience.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04497922; https://clinicaltrials.gov/ct2/show/NCT04497922.

Developing a Memory and Communication App for Persons Living With Dementia: An 8-Step Process

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.3928/19404921-20210825-02.

Wrist Accelerometer Estimates of Physical Activity Intensity During Walking in Older Adults and People Living With Complex Health Conditions: Retrospective Observational Data Analysis Study

BACKGROUND

Accurate measurement of daily physical activity (PA) is important as PA is linked to health outcomes in older adults and people living with complex health conditions. Wrist-worn accelerometers are widely used to estimate PA intensity, including walking, which composes much of daily PA. However, there is concern that wrist-derived PA data in these cohorts is unreliable due to slow gait speed, mobility aid use, disease-related symptoms that impact arm movement, and transient activities of daily living. Despite the potential for error in wrist-derived PA intensity estimates, their use has become ubiquitous in research and clinical application.

OBJECTIVE

The goals of this work were to (1) determine the accuracy of wrist-based estimates of PA intensity during known walking periods in older adults and people living with cerebrovascular disease (CVD) or neurodegenerative disease (NDD) and (2) explore factors that influence wrist-derived intensity estimates.

METHODS

A total of 35 older adults (n=23 with CVD or NDD) wore an accelerometer on the dominant wrist and ankle for 7 to 10 days of continuous monitoring. Stepping was detected using the ankle accelerometer. Analyses were restricted to gait bouts ≥60 seconds long with a cadence ≥80 steps per minute (LONG walks) to identify periods of purposeful, continuous walking likely to reflect moderate-intensity activity. Wrist accelerometer data were analyzed within LONG walks using 15-second epochs, and published intensity thresholds were applied to classify epochs as sedentary, light, or moderate-to-vigorous physical activity (MVPA). Participants were stratified into quartiles based on the percent of walking epochs classified as sedentary, and the data were examined for differences in behavioral or demographic traits between the top and bottom quartiles. A case series was performed to illustrate factors and behaviors that can affect wrist-derived intensity estimates during walking.

RESULTS

Participants averaged 107.7 (SD 55.8) LONG walks with a median cadence of 107.3 (SD 10.8) steps per minute. Across participants, wrist-derived intensity classification was 22.9% (SD 15.8) sedentary, 27.7% (SD 14.6) light, and 49.3% (SD 25.5) MVPA during LONG walks. All participants measured a statistically lower proportion of wrist-derived activity during LONG walks than expected (all P<.001), and 80% (n=28) of participants had at least 20 minutes of LONG walking time misclassified as sedentary based on wrist-derived intensity estimates. Participants in the highest quartile of wrist-derived sedentary classification during LONG walks were significantly older (t₁₆=4.24, P<.001) and had more variable wrist movement (t₁₆=2.13, P=.049) compared to those in the lowest quartile.

CONCLUSIONS

The current best practice wrist accelerometer method is prone to misclassifying activity intensity during walking in older adults and people living with complex health conditions. A multidevice approach may be warranted to advance methods for accurately assessing PA in these groups.

The Impact of Digital Health on Smoking Cessation

BACKGROUND

Smartphones have become useful tools for medicine, with the use of specific apps making it possible to bring health care closer to inaccessible areas, continuously monitor a patient's pathology at any time and place, promote healthy habits, and ultimately improve patients' quality of life and the efficiency of the health care system. Since 2020, the use of smartphones has reached unprecedented levels. There are more than 350,000 health apps, according to a 2021 IQVIA Institute report, that address, among other things, the management of patient appointments; communication among different services or professionals; the promotion of lifestyle changes related to adopting healthy habits; and the monitoring of different pathologies and chronic conditions, including smoking cessation. The number of mobile apps for quitting smoking is high. As early as 2017, a total of 177 unique smoking cessation-relevant apps were identified in the iPhone App Store, 139 were identified in Google Play, 70 were identified in the BlackBerry app store, and 55 were identified in the Windows Phone Store, but very few have adequate scientific support. It seems clear that efforts are needed to assess the quality of these apps, as well as their effectiveness in different population groups, to have tools that offer added value to standard practices.

OBJECTIVE

This viewpoint aims to highlight the benefits of mobile health (mHealth) and its potential as an adjuvant tool in health care.

METHODS

A review of literature and other data sources was performed in order to show the current status of mobile apps that can offer support for smoking cessation. For this purpose, the PubMed, Embase, and Cochrane databases were explored between May and November 2022.

RESULTS

In terms of smoking cessation, mHealth has become a powerful coadjuvant tool that allows health workers to perform exhaustive follow-ups for the process of quitting tobacco and provide support anytime and anywhere. mHealth tools are effective for different groups of smokers (eg, pregnant women, patients with chronic obstructive pulmonary disease, patients with mental illness, and the general population) and are cost-effective, generating savings for the health system. However, there are some patient characteristics that can predict the success of using mobile apps in the smoking cessation process, such as the lower age of patients, dependence on tobacco, the number of quit attempts, and the previous use of mobile apps, among others. Therefore, it is preferable to offer these tools to patients with a higher probability of quitting tobacco.

CONCLUSIONS

mHealth is a promising tool for helping smokers in the smoking cessation process. There is a need for well-designed clinical studies and economic evaluations to jointly assess the effectiveness of new interventions in different population groups, as well as their impact on health care resources.

Distinct phenotypes of kidney transplant recipients aged 80 years or older in the USA by machine learning consensus clustering

Objectives

This study aimed to identify distinct clusters of very elderly kidney transplant recipients aged ≥80 and assess clinical outcomes among these unique clusters.

Design

Cohort study with machine learning (ML) consensus clustering approach.

Setting and participants

All very elderly (age ≥80 at time of transplant) kidney transplant recipients in the Organ Procurement and Transplantation Network/United Network for Organ Sharing database database from 2010 to 2019.

Main outcome measures

Distinct clusters of very elderly kidney transplant recipients and their post-transplant outcomes including death-censored graft failure, overall mortality and acute allograft rejection among the assigned clusters.

Results

Consensus cluster analysis was performed in 419 very elderly kidney transplant and identified three distinct clusters that best represented the clinical characteristics of very elderly kidney transplant recipients. Recipients in cluster 1 received standard Kidney Donor Profile Index (KDPI) non-extended criteria donor (ECD) kidneys from deceased donors. Recipients in cluster 2 received kidneys from older, hypertensive ECD deceased donors with a KDPI score ≥85%. Kidneys for cluster 2 patients had longer cold ischaemia time and the highest use of machine perfusion. Recipients in clusters 1 and 2 were more likely to be on dialysis at the time of transplant (88.3%, 89.4%). Recipients in cluster 3 were more likely to be preemptive (39%) or had a dialysis duration less than 1 year (24%). These recipients received living donor kidney transplants. Cluster 3 had the most favourable post-transplant outcomes. Compared with cluster 3, cluster 1 had comparable survival but higher death-censored graft failure, while cluster 2 had lower patient survival, higher death-censored graft failure and more acute rejection.

Conclusions

Our study used an unsupervised ML approach to cluster very elderly kidney transplant recipients into three clinically unique clusters with distinct post-transplant outcomes. These findings from an ML clustering approach provide additional understanding towards individualised medicine and opportunities to improve care for very elderly kidney transplant recipients.

Rapid triage and transition to telehealth for heart transplant patients in the COVID-19 pandemic setting

BACKGROUND

In the setting of the COVID-19 pandemic, a rapid uptake of telehealth services was instituted with the aim of reducing the spread of disease to vulnerable patient populations including heart transplant recipients.

METHODS

Single-center, cohort study of all heart transplant patients seen by our institution's transplant program during the first 6 weeks of transition from in-person consultation to telehealth (23 March - 5 June 2020).

RESULTS

Face-to-face consultation allocation strongly favored patients in the early post-operative period (34 vs. 242 weeks post-transplant; p < 0.001). Telehealth consultation dramatically reduced patient travel and wait times (80 min per visit saved in telehealth patients). No apparent excess re-hospitalization or mortality was seen in telehealth patients.

CONCLUSIONS

With appropriate triage, telehealth was feasible in heart transplant recipients, with videoconferencing being the preferred modality. Patients seen face-to-face were those triaged to be higher acuity based on time since transplant and overall clinical status. These patients have the expected higher rates of hospital re-admission, and therefore should continue to be seen in person.

eHealth Literacy and Patient Portal Use and Attitudes: Cross-sectional Observational Study

BACKGROUND

Throughout the COVID-19 pandemic, patient portals have become more widely used tools of patient care delivery. However, not all individuals have equivalent access or ability to use patient portals.

OBJECTIVE

The aim of this study is to evaluate the relationships between eHealth literacy (eHL) and patient portal awareness, use, and attitudes among hospitalized patients.

METHODS

Inpatients completed patient portal surveys; eHL was assessed (eHealth Literacy Scale). Multivariable logistic regression analyses adjusted for age, self-reported race, gender, and educational attainment were completed with significance at P<.006 (Bonferroni correction).

RESULTS

Among 274 participants, most identified as Black (n=166, 61%) and female (n=140, 51%), mean age was 56.5 (SD 16.7) years, and 178 (65%) reported some college or higher educational attainment. One-quarter (n=79, 28%) had low eHL (mean 27, SD 9.5), which was associated with lower odds of portal access awareness (odds ratio 0.11, 95% CI 0.05-0.23; P<.001), having ever used portals (odds ratio 0.19, 95% CI 0.10-0.36; P<.001), less perceived usefulness of portals (odds ratio 0.20, 95% CI 0.10-0.38; P=.001), and lower likelihood of planning to use portals in the coming years (odds ratio 0.12, 95% CI 0.06-0.25; P<.001). As time through the COVID-19 pandemic passed, there was a trend toward increased perceived usefulness of patient portals (53% vs 62%, P=.08), but average eHL did not increase through time (P=.81).

CONCLUSIONS

Low eHL was associated with less awareness, use, and perceived usefulness of portals. Perceived usefulness of portals likely increased through the COVID-19 pandemic, but patients' eHL did not. Interventions tailored for patients with low eHL could ensure greater equity in health care delivery through the COVID-19 pandemic.