Qualitative Analysis of Perspectives on Lung Transplant among People with Cystic Fibrosis

RATIONALE

Lung transplant (LTx) is a potentially life-saving treatment option for individuals with advanced cystic fibrosis (CF), but more people with CF (PwCF) and advanced lung disease die each year than undergo transplant in the United States. Little is known about these individuals' LTx information needs and factors influencing their decision-making process related to transplant.

OBJECTIVES

To examine PwCF's experiences with, and preferences for, provision of LTx information; to identify transplant information needs that CF clinicians are well-positioned to address.

METHODS

We performed semi-structured qualitative interviews in two separate cohorts: PwCF without LTx and PwCF with LTx between July 2019 and June 2020. Questions focused on awareness and knowledge about LTx, perspectives related to communication about transplant in CF clinic, and experiences with LTx. Thematic analysis was utilized to organize the qualitative data. Exemplar quotes were chosen to illustrate domains that emerged pertaining to the research objectives.

RESULTS

Fifty-five PwCF, 35 without LTx and 20 with LTx, participated. One-third of PwCF without LTx had normal or near-normal lung function. Key common domains among PwCF with and without LTx were identified including information needs, connections with LTx recipients, and conversations with CF clinicians. For PwCF with and without transplant, concrete information needs were identified: success or survival, social support, surgery, recovery/pain, and quality of life post-transplant. The importance of connecting with LTx recipients to hear their stories and experiences was emphasized by both PwCF with and without transplant. Important considerations for timing and content of discussions with CF clinicians were identified, including having information presented early (before LTx referral is needed) and in limited detail at first. PwCF without LTx wanted to understand how LTx was relevant to them, with a focus on the unique experience of CF. PwCF with LTx emphasized the need for a centralized resource for LTx information.

CONCLUSIONS

The findings provide content areas for CF clinicians to focus on as they proactively initiate conversations about LTx and support the development of tools to aid in discussions about LTx for PwCF.

Imagining Improved Interactions: Patients' Designs To Address Implicit Bias

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

Co-designing mind-body technologies for sleep with adolescents

Sleep is critical for well-being, yet adolescents do not get enough sleep. Mind-body approaches can help. Despite the potential of technology to support mind-body approaches for sleep, there is a lack of research on adolescent preferences for digital mind-body technology. We use co-design to examine adolescent perspectives on mind-body technologies for sleep. From our analysis of design sessions with 16 adolescents, four major themes emerged: system behavior, modality, content, and context. In light of these key findings, we recommend that technology-based mind-body approaches to sleep for adolescents be designed to 1) serve multiple functions while avoiding distractions, 2) provide intelligent content while maintaining privacy and trust, 3) provide a variety of content with the ability to customize and personalize, 4) offer multiple modalities for interaction with technology, and 5) consider the context of adolescent and their families. Findings provide a foundation for designing mind-body technologies for adolescent sleep.

Improving physical activity among prostate cancer survivors through a peer-based digital walking program

Physical activity is important for prostate cancer survivors. Yet survivors face significant barriers to traditional structured exercise programs, limiting engagement and impact. Digital programs that incorporate fitness trackers and peer support via social media have potential to improve the reach and impact of traditional support. Using a digital walking program with prostate cancer survivors, we employed mixed methods to assess program outcomes, engagement, perceived utility, and social influence. After 6 weeks of program use, survivors and loved ones (n=18) significantly increased their average daily step count. Although engagement and perceived utility of using a fitness tracker and interacting with walking buddies was high, social media engagement and utility were limited. Group strategies associated with social influence were driven more by group attraction to the collective task of walking than by interpersonal bonds. Findings demonstrate the feasibility of a digital walking program to improve physical activity and extend the reach of traditional support.

Improving Vaccine Equity: How Community Engagement and Informatics Facilitate Health System Outreach to Underrepresented Groups

BACKGROUND

Given the inequities in access to health care resources like COVID-19 vaccination, health systems should carefully consider how to reach underrepresented groups. Reflecting on vaccine rollout efforts holds insight on the role of community engagement and informatics support in promoting health equity.

OBJECTIVES

This study aimed to assess the effectiveness of four outreach strategies deployed by University of Washington (UW) Medicine in improving vaccine equity over traditional vaccine scheduling online or by phone, we report on appointment scheduling and completion of appointments (i.e., vaccine administration) through (1) automated outreach to individuals from underrepresented groups, (2) temporary "pop-up" clinics in neighborhoods highly impacted by COVID-19, (3) vulnerable population clinics, and (4) mobile vaccine vans.

METHODS

We conducted a 6-month retrospective analysis of electronic health records (EHR) to describe the sociodemographic characteristics of individuals who scheduled appointments using the outreach strategies and characteristics associated with a greater likelihood of vaccine administration based on appointment completion. To help explain trends in the EHR data, we engaged 10 health system leaders and staff who spearheaded the outreach strategies in follow-up conversations to identify qualitative insights into what worked and why.

RESULTS

Compared with traditional scheduling, all outreach strategies except vulnerable population clinics had higher vaccine appointment completion rates, including automated outreach (N = 3,734 [94.7%], p < 0.001), pop-up clinics (N = 4,391 [96.0%], p < 0.001), and mobile vans (N = 4,198 [99.1%], p < 0.001); and lower cancellation rates, including automated outreach (N = 166 [1.1%], p < 0.001), pop-up clinics (N = 155 [0.6%], p < 0.001), and mobile vans (N = 0 [0%], p < 0.001). Qualitative insights emphasized ongoing community partnerships and information resources in successful outreach.

CONCLUSION

Vaccine equity outreach strategies improved the proportion of patients who scheduled and completed vaccination appointments among populations disproportionately impacted by COVID-19. Engaging community partners and equity-focused informatics tools can facilitate outreach. Lessons from these outreach strategies carry practical implications for health systems to amplify their health equity efforts.

Integrating patient voices into the extraction of social determinants of health from clinical notes: ethical considerations and recommendations

Identifying patients' social needs is a first critical step to address social determinants of health (SDoH)-the conditions in which people live, learn, work, and play that affect health. Addressing SDoH can improve health outcomes, population health, and health equity. Emerging SDoH reporting requirements call for health systems to implement efficient ways to identify and act on patients' social needs. Automatic extraction of SDoH from clinical notes within the electronic health record through natural language processing offers a promising approach. However, such automated SDoH systems could have unintended consequences for patients, related to stigma, privacy, confidentiality, and mistrust. Using Floridi et al's "AI4People" framework, we describe ethical considerations for system design and implementation that call attention to patient autonomy, beneficence, nonmaleficence, justice, and explicability. Based on our engagement of clinical and community champions in health equity work at University of Washington Medicine, we offer recommendations for integrating patient voices and needs into automated SDoH systems.

Geospatial divide in real-world EHR data: Analytical workflow to assess regional biases and potential impact on health equity

Real-world data (RWD) like electronic health records (EHR) has great potential for secondary use by health systems and researchers. However, collected primarily for efficient health care, EHR data may not equitably represent local regions and populations, impacting the generalizability of insights learned from it. We assessed the geospatial representativeness of regions in a large health system EHR data using a spatial analysis workflow, which provides a data-driven way to quantify geospatial representation and identify adequately represented regions. We applied the workflow to investigate geospatial patterns of overweight/obesity and depression patients to find regional "hotspots" for potential targeted interventions. Our findings show the presence of geospatial bias in EHR and demonstrate the workflow to identify spatial clusters after adjusting for bias due to the geospatial representativeness. This work highlights the importance of evaluating geospatial representativeness in RWD to guide targeted deployment of limited healthcare resources and generate equitable real-world evidence.

Take on transplant: human-centered design of a patient education tool to facilitate informed discussions about lung transplant among people with cystic fibrosis

OBJECTIVE

Lung transplant (LTx) saves lives in cystic fibrosis (CF). However, many potential candidates express uncertainty about LTx and die before receiving this treatment. CF guidelines recommend LTx education and clinical discussions well before the need for LTx arises, but limited patient resources exist.

MATERIALS AND METHODS

We engaged people with CF and CF physicians in human-centered design of "Take On Transplant" (TOT), a web-based education tool to prepare patients for LTx discussions. Across 3 phases, needs assessment, design groups, and iterative user testing of TOT, we refined TOT from wireframe prototypes, to an interactive website, to a fully functional intervention ready for clinical trials.

RESULTS

Fifty-five people with CF and 105 physicians identified information needs to prepare for LTx discussions. Design groups (n = 14 participants) then established core requirements: didactic education ("Resource Library"), patient narratives ("CF Stories"), frequently asked questions ("FAQ"), and self-assessment to tailor content ("My CF Stage"). Iterative usability testing (n = 39) optimized the design of CF Stories and prototype layout. We then developed the TOT website and demonstrated feasibility and preliminary efficacy of use through 2-week field testing (n = 9).

DISCUSSION

Our human-centered design process provided guidance for educational tools to serve the evolving needs of potential LTx candidates. Our findings support the process of patient deliberation as a foundation for shared decision-making in CF, and inform educational tools that could potentially translate beyond LTx.

CONCLUSION

TOT fills a critical gap in preparing people with CF for shared decision-making about LTx and may serve as a model for educational tools for other preference-sensitive decisions.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSIONS

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

Comprehension, utility, and preferences of prostate cancer survivors for visual timelines of patient-reported outcomes co-designed for limited graph literacy: meters and emojis over comics

OBJECTIVE

Visual timelines of patient-reported outcomes (PRO) can help prostate cancer survivors manage longitudinal data, compare with population averages, and consider future trajectories. PRO visualizations are most effective when designed with deliberate consideration of users. Yet, graph literacy is often overlooked as a design constraint, particularly when users with limited graph literacy are not engaged in their development. We conducted user testing to assess comprehension, utility, and preference of longitudinal PRO visualizations designed for prostate cancer survivors with limited literacy.

MATERIALS AND METHODS

Building upon our prior work co-designing longitudinal PRO visualizations with survivors, we engaged 18 prostate cancer survivors in a user study to assess 4 prototypes: Meter, Words, Comic, and Emoji. During remote sessions, we collected data on prototype comprehension (gist and verbatim), utility, and preference.

RESULTS

Participants were aged 61-77 (M = 69), of whom half were African American. The majority of participants had less than a college degree (95%), had inadequate health literacy (78%), and low graph literacy (89%). Among the 4 prototypes, Meter had the best gist comprehension and was preferred. Emoji was also preferred, had the highest verbatim comprehension, and highest rated utility, including helpfulness, confidence, and satisfaction. Meter and Words both rated mid-range for utility, and Words scored lower than Emoji and Meter for comprehension. Comic had the poorest comprehension, lowest utility, and was least preferred.

DISCUSSION

Findings identify design considerations for PRO visualizations, contributing to the knowledge base for visualization best practices. We describe our process to meaningfully engage patients from diverse and hard-to-reach groups for remote user testing, an important endeavor for health equity in biomedical informatics.

CONCLUSION

Graph literacy is an important design consideration for PRO visualizations. Biomedical informatics researchers should be intentional in understanding user needs by involving diverse and representative individuals during development.

Implementation matters: How patient experiences differ when genetic counseling accompanies the return of genetic variants of uncertain significance

Precision medicine presents challenges for effective return of results (ROR) to patients, particularly for variants of uncertain significance (VUS) where the need for genetic counseling and the impact of results are underexplored. We investigated patients' experiences with VUS ROR. Through interviews we compared experiences of patients who were referred to genetic counseling with those not referred. Although participants from both groups (n=16) reported curious enthusiasm and relief after ROR, the 5 referred participants reported less confusion, less disappointment, and better confidence in understanding their results than the 11 non-referred participants. Although VUS did not impact healthcare or daily lives, some participants who shared VUS fostered communication about future healthcare. Suggested ROR improvements included patient-friendly terminology, on-demand education, and ongoing consultation. Although patient experience of VUS improved when ROR involved expert consultation, scarcity of genetic counselors presents challenges. Improving the ROR process with patient-centered solutions could enhance the patient experience of receiving VUS.

Design of digital walking programs that engage prostate cancer survivors: Needs and preferences from focus groups

The majority of prostate cancer survivors do not meet physical activity (PA) recommendations. Although technology has shown to promote PA, engagement has been a challenge. This mixed method study characterizes survivors' needs and preferences for digital walking programs Through focus groups and surveys, we engaged prostate cancer support groups to describe PA motivators and barriers, interest in improving PA, and preferences for design features of a future digital walking program. Identified motivators (peers, positive thinking) and barriers (health issues) reflect PA needs that impact engagement. The most preferred features include: (1) well-curated, specific content, (2) individualized feedback from trusted sources, (3) moderated peer discussion, and (4) support from small teams and peer mentors. These findings inform digital PA programs that survivors will find engaging and can promote PA.

Usability preferences of people living with cystic fibrosis about a lung transplant education website

People living with cystic fibrosis (CF) need educational resources about lung transplant prior to engaging in shared decision making with their medical providers. We conducted a usability study to elicit preferences of people living with CF about how didactic and experiential content could be used in an educational resource to learn about lung transplant. We created two prototypes with different design features that participants used in a scenario-based task and evaluated using the System Usability Scale. We interviewed participants and analyzed the data to understand their preferences for educational content and design. Study participants indicated that didactic resource articles were important to understanding their illness trajectory, while experiential patient stories supported fear reduction and knowledge discovery. When learning about lung transplant participants stated a preference to control the amount of information they receive and preferred a combination of didactic and experiential knowledge.

Approaches for implementing digital interventions for alcohol use disorders in primary care: A qualitative, user-centered design study

Background

Digital interventions, such as smartphone apps, can be effective in treating alcohol use disorders (AUD). However, efforts to integrate digital interventions into primary care have been challenging. To inform successful implementation, we sought to understand how patients and clinicians preferred to use apps in routine primary care.

Methods

This study combined user-centered design and qualitative research methods, interviewing 18 primary care patients with AUD and nine primary care clinicians on topics such as prior experiences with digital tools, and design preferences regarding approaches for offering apps for AUD in primary care. Interviews were recorded and transcribed for template analysis whereby a priori codes were based on interview topics and refined through iterative coding. New codes and cross-cutting themes emerged from the data.

Results

Patient participants with AUD indicated they would be more likely to engage in treatment if primary care team members were involved in their use of apps. They also preferred to see clinicians “invested” and recommended that clinicians ask about app use and progress during follow-up appointments or check-ins. Clinician participants valued the opportunity to offer apps to their patients but noted that workflows would need to be tailored to individual patient needs. Time pressures, implementation complexity, and lack of appropriate staffing were cited as barriers. Clinicians proposed concrete solutions (e.g., education, tools, and staffing models) that could improve their ability to use apps within the constraints of primary care and suggested that some patients could potentially use apps without clinician support.

Conclusions

A user-centered approach to engaging patients in digital alcohol interventions in primary care may require personalized support for both initiation and follow-up. Meeting patients’ needs likely require increased staffing and efficient workflows in primary care. Health systems should consider offering multiple pathways for enrolling patients in apps to accommodate individual preferences and contextual barriers.

Plain Language Summary

Healthcare systems have begun using app-based treatments to help patients manage their health conditions, including alcohol use disorders. Some apps have been tested in research studies and appear to be effective. However, it is difficult for healthcare teams to offer apps to patients. Clinicians must engage in new activities that they have not done before, such as “teaching” patients to use apps and checking in on their use of the apps. Identifying how to use apps in routine healthcare is critical to their successful implementation. This study interviewed 27 people, including healthcare providers and patients in primary care, to uncover the most optimal ways to offer apps to patients with alcohol use disorders. The interviews combined the use of qualitative research methods and user-centered design. Results suggest that to use to address alcohol use disorders, primary care teams should be prepared to offer personalized support to patients. Both patient and clinician interviewees said that the steps required to use apps must be intuitive and simple. Patients could gain more benefits if clinicians introduced the apps and guided patients to use them, as opposed to making apps available for patients to download and use on their own. However, the exact approach to offering apps would depend on a given patient’s preferences and the extent that staffing was available in the clinic to support patients. Health systems should be prepared to offer and support patients in their use of apps, which should accommodate patient preferences and the constraints of the clinic.

Comparing Caregiving Needs in Asian And White Family Caregivers through a Journaling Exercise Delivered by a Conversational Agent

Asian Americans are the fastest growing racial and ethnic group with nearly 1 in 5 self-identifying as a family caregiver. Understanding the needs of ethnic minority caregivers is needed to develop inclusive technology solutions that aim to support caregivers within these marginalized communities in managing their own health. This study aimed to describe and compare the common needs of Asian American (AA) and White caregivers through data collected using a short message service-based conversational agent. Caregivers (26 AA and 84 White) shared their daily experiences for 14 days, and the data were analyzed using directed content analysis to identify needs based on Maslow's Hierarchy of Needs. Overall, AA and White caregivers expressed different needs in physiological, safety, and esteem categories. Culturally tailored support and resources are needed for family caregivers from diverse cultural and ethnic backgrounds.

Exploring needs, interests and preferences for digital mind-body tools for adolescents

Sleep problems are common among adolescents and research on mind-body interventions for sleep is promising. Although technology-based mind-body interventions have been shown to help early adolescents with practicing mind-body approaches, engagement and adherence has been a challenge. Using a Human-Centered Design framework with semi-structured interviews with parent-adolescent dyads, we describe exposure to, interest in, and preferences for digital mind-body technology for sleep. Identified challenges (e.g., 'establish routine', 'busy schedule) and preferences (e.g., age-appropriate content) reflect mind-body technology needs that impact engagement. Based on these findings, we recommend that a technology-based mind-body approach for early adolescents be designed to 1) provide content customized for adolescents 2) include functionalities that engage adolescents like games and rewards, and 3) allow for granular sharing controls. These recommendations provide a foundation for designing digital mind-body tools for adolescents.

A learning health systems approach to integrating electronic patient-reported outcomes across the health care organization

INTRODUCTION

Foundational to a learning health system (LHS) is the presence of a data infrastructure that can support continuous learning and improve patient outcomes. To advance their capacity to drive patient-centered care, health systems are increasingly looking to expand the electronic capture of patient data, such as electronic patient-reported outcome (ePRO) measures. Yet ePROs bring unique considerations around workflow, measurement, and technology that health systems may not be poised to navigate. We report on our effort to develop generalizable learnings that can support the integration of ePROs into clinical practice within an LHS framework.

METHODS

Guided by action research methodology, we engaged in iterative cycles of planning, acting, observing, and reflecting around ePRO use with two primary goals: (1) mobilize an ePRO community of practice to facilitate knowledge sharing, and (2) establish guidelines for ePRO use in the context of LHS practice. Multiple, emergent data collection activities generated generalizable guidelines that document the tangible best practices for ePRO use in clinical care. We organized guidelines around thematic areas that reflect LHS structures and stakeholders.

RESULTS

Three core thematic areas (and 24 guidelines) emerged. The theme of governance reflects the importance of leadership, knowledge management, and facilitating organizational learning around best practice models for ePRO use. The theme of integration considers the intersection of workflow, technology, and human factors for ePROs across areas of care delivery. Lastly, the theme of reporting reflects critical considerations for curating data and information, designing system functions and interactions, and presentation of ePRO data to support the translation of knowledge to action.

CONCLUSIONS

The guidelines produced from this work highlight the complex, multidisciplinary nature of implementing change within LHS contexts, and the value of action research approaches to enable rapid, iterative learning that leverages the knowledge and experience of communities of practice.

Personal health information management among healthy older adults: Varying needs and approaches

OBJECTIVE

With age, older adults experience a greater number of chronic diseases and medical visits, and an increased need to manage their health information. Technological advances in consumer health information technologies (HITs) help patients gather, track, and organize their health information within and outside of clinical settings. However, HITs have not focused on the needs of older adults and their caregivers. The goal of the SOARING (Studying Older Adults and Researching their Information Needs and Goals) Project was to understand older adult personal health information management (PHIM) needs and practices to inform the design of HITs that support older adults.

MATERIALS AND METHODS

Drawing on the Work System Model, we took an ecological approach to investigate PHIM needs and practices of older adults in different residential settings. We conducted in-depth interviews and surveys with adults 60 years of age and older.

RESULTS

We performed on-site in-person interview sessions with 88 generally healthy older adults in various settings including independent housing, retirement communities, assisted living, and homelessness. Our analysis revealed 5 key PHIM activities that older adults engage in: seeking, tracking, organizing, sharing health information, and emergency planning. We identified 3 major themes influencing older adults' practice of PHIM: (1) older adults are most concerned with maintaining health and preventing illness, (2) older adults frequently involve others in PHIM activities, and (3) older adults' approach to PHIM is situational and context-dependent.

DISCUSSION

Older adults' approaches to PHIM are dynamic and sensitive to changes in health, social networks, personal habits, motivations, and goals.

CONCLUSIONS

PHIM tools that meet the needs of older adults should accommodate the dynamic nature of aging and variations in individual, organizational, and social contexts.

Approaches for Implementing App-Based Digital Treatments for Drug Use Disorders Into Primary Care: A Qualitative, User-Centered Design Study of Patient Perspectives

Background

Digital interventions, such as websites and smartphone apps, can be effective in treating drug use disorders (DUDs). However, their implementation in primary care is hindered, in part, by a lack of knowledge on how patients might like these treatments delivered to them.

Objective

This study aims to increase the understanding of how patients with DUDs prefer to receive app-based treatments to inform the implementation of these treatments in primary care.

Methods

The methods of user-centered design were combined with qualitative research methods to inform the design of workflows for offering app-based treatments in primary care. Adult patients (n=14) with past-year cannabis, stimulant, or opioid use disorder from 5 primary care clinics of Kaiser Permanente Washington in the Seattle area participated in this study. Semistructured interviews were recorded, transcribed, and analyzed using qualitative template analysis. The coding scheme included deductive codes based on interview topics, which primarily focused on workflow design. Inductive codes emerged from the data.

Results

Participants wanted to learn about apps during visits where drug use was discussed and felt that app-related conversations should be incorporated into the existing care whenever possible, as opposed to creating new health care visits to facilitate the use of the app. Nearly all participants preferred receiving clinician support for using apps over using them without support. They desired a trusting, supportive relationship with a clinician who could guide them as they used the app. Participants wanted follow-up support via phone calls or secure messaging because these modes of communication were perceived as a convenient and low burden (eg, no copays or appointment travel).

Conclusions

A user-centered implementation of treatment apps for DUDs in primary care will require health systems to design workflows that account for patients’ needs for structure, support in and outside of visits, and desire for convenience.

Comparison of women and men in biomedical informatics scientific dissemination: retrospective observational case study of the AMIA Annual Symposium: 2017-2020

OBJECTIVE

Although the representation of women in science has improved, women remain underrepresented in scientific publications. This study compares women and men in scholarly dissemination through the AMIA Annual Symposium.

MATERIALS AND METHODS

Through a retrospective observational study, we analyzed 2017-2020 AMIA submissions for differences in panels, papers, podium abstracts, posters, workshops, and awards for men compared with women. We assigned a label of woman or man to authors and reviewers using Genderize.io, and then compared submission and acceptance rates, performed regression analyses to evaluate the impact of the assumed gender, and performed sentiment analysis of reviewer comments.

RESULTS

Of the 4687 submissions for which Genderize.io could predict man or woman based on first name, 40% were led by women and 60% were led by men. The acceptance rate was smilar. Although submission and acceptance rates for women increased over the 4 years, women-led podium abstracts, panels, and workshops were underrepresented. Men reviewers increased the odds of rejection. Men provided longer reviews and lower reviewer scores, but women provided reviews that had more positive words.

DISCUSSION

Overall, our findings reflect significant gains for women in the 4 years of conference data analyzed. However, there remain opportunities to improve representation of women in workshop submissions, panel and podium abstract speakers, and balanced peer reviews. Future analyses could be strengthened by collecting gender directly from authors, including diverse genders such as non-binary.

CONCLUSION

We found little evidence of major bias against women in submission, acceptance, and awards associated with the AMIA Annual Symposium from 2017 to 2020. Our study is unique because of the analysis of both authors and reviewers. The encouraging findings raise awareness of progress and remaining opportunities in biomedical informatics scientific dissemination.

Information needs and priority use cases of population health researchers to improve preparedness for future hurricanes and floods

OBJECTIVE

Information gaps that accompany hurricanes and floods limit researchers' ability to determine the impact of disasters on population health. Defining key use cases for sharing complex disaster data with research communities and facilitators, and barriers to doing so are key to promoting population health research for disaster recovery.

MATERIALS AND METHODS

We conducted a mixed-methods needs assessment with 15 population health researchers using interviews and card sorting. Interviews examined researchers' information needs by soliciting barriers and facilitators in the context of their expertise and research practices. Card sorting ranked priority use cases for disaster preparedness.

RESULTS

Seven barriers and 6 facilitators emerged from interviews. Barriers to collaborative research included process limitations, collaboration dynamics, and perception of research importance. Barriers to data and technology adoption included data gaps, limitations in information quality, transparency issues, and difficulty to learn. Facilitators to collaborative research included collaborative engagement and human resource processes. Facilitators to data and technology adoption included situation awareness, data quality considerations, adopting community standards, and attractive to learn. Card sorting prioritized 15 use cases and identified 30 additional information needs for population health research in disaster preparedness.

CONCLUSIONS

Population health researchers experience barriers to collaboration and adoption of data and technology that contribute to information gaps and limit disaster preparedness. The priority use cases we identified can help address information gaps by informing the design of supportive research tools and practices for disaster preparedness. Supportive tools should include information on data collection practices, quality assurance, and education resources usable during failures in electric or telecommunications systems.

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

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

Safer use of antipsychotics in youth (SUAY) pragmatic trial protocol

BACKGROUND

Programs such as the Pediatric Access Line in Washington state have shown decreases in antipsychotic medication use by youth with non-psychotic disorders. Program outcomes have been studied with observational designs. This manuscript describes the protocol for Targeted and Safer Use of Antipsychotics in Youth (SUAY), a randomized controlled trial of psychiatrist review of prescriptions and facilitated access to psychosocial care. The aim of the intervention is to reduce the number of person-days of antipsychotic use among participants.

METHODS

Recruitment occurs at 4 health systems. Targeted enrollment is 800 youth aged 3-17 years. Clinicians are block randomized to intervention versus usual care prior to the study. Youth are nested within the arm of the prescribing clinician. Clinicians in the intervention group receive an EHR-based best practice alert with options to expedite access to psychosocial care and all medication orders are reviewed by a child and adolescent psychiatrist with feedback provided to the prescriber. The primary outcome is person-days of antipsychotic medication use in the 6 months following the initial order. All randomized individuals contribute data regardless of their level of participation (including declining all services).

DISCUSSION

The trial has been approved by the institutional review boards at each of the 4 sites. The intervention has 4 novel design features including automated recruitment using a best practice alert, psychiatrist medication order review and consultation, telephone navigation to psychosocial care, and telemental health visits. Recruitment began in March of 2018 and will be completed in June 2020. Follow-up will be completed December 31, 2020.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT03448575.

Designing an AI Health Coach and Studying Its Utility in Promoting Regular Aerobic Exercise

Our research aims to develop interactive, social agents that can coach people to learn new tasks, skills, and habits. In this article, we focus on coaching sedentary, overweight individuals (i.e., “trainees”) to exercise regularly. We employ adaptive goal setting in which the intelligent health coach generates, tracks, and revises personalized exercise goals for a trainee. The goals become incrementally more difficult as the trainee progresses through the training program. Our approach is model-based—the coach maintains a parameterized model of the trainee’s aerobic capability that drives its expectation of the trainee’s performance. The model is continually revised based on trainee-coach interactions. The coach is embodied in a smartphone application, N utri W alking , which serves as a medium for coach-trainee interaction. We adopt a task-centric evaluation approach for studying the utility of the proposed algorithm in promoting regular aerobic exercise. We show that our approach can adapt the trainee program not only to several trainees with different capabilities but also to how a trainee’s capability improves as they begin to exercise more. Experts rate the goals selected by the coach better than other plausible goals, demonstrating that our approach is consistent with clinical recommendations. Further, in a 6-week observational study with sedentary participants, we show that the proposed approach helps increase exercise volume performed each week.

Defining Success in Measurement-Based Care for Depression: A Comparison of Common Metrics

OBJECTIVE

The National Committee for Quality Assurance recommends response and remission as indicators of successful depression treatment for the Healthcare Effectiveness and Data Information Set. Effect size and severity-adjusted effect size (SAES) offer alternative metrics. This study compared measures and examined the relationship between baseline symptom severity and treatment success.

METHODS

Electronic records from two large integrated health systems (Kaiser Permanente Colorado and Washington) were used to identify 5,554 new psychotherapy episodes with a baseline Patient Health Questionnaire (PHQ-9) score of ≥10 and a PHQ-9 follow-up score from 14-180 days after treatment initiation. Treatment success was defined for four measures: response (≥50% reduction in PHQ-9 score), remission (PHQ-9 score <5), effect size ≥0.8, and SAES ≥0.8. Descriptive analyses examined agreement of measures. Logistic regression estimated the association between baseline severity and success on each measure. Sensitivity analyses evaluated the impact of various outcome definitions and loss to follow-up.

RESULTS

Effect size ≥0.8 was most frequently attained (72% across sites), followed by SAES ≥0.8 (66%), response (46%), and remission (22%). Response was the only measure not associated with baseline PHQ-9 score. Effect size ≥0.8 favored episodes with a higher baseline PHQ-9 score (odds ratio [OR]=2.3, p<0.001, for 10-point difference in baseline PHQ-9 score), whereas SAES ≥0.8 (OR=0.61, p<0.001) and remission (OR=0.43, p<0.001) favored episodes with lower baseline scores.

CONCLUSIONS

Response is preferable for comparing treatment outcomes, because it does not favor more or less baseline symptom severity, indicates clinically meaningful improvement, and is transparent and easy to calculate.

Capturing the patient voice: implementing patient-reported outcomes across the health system

PURPOSE

Supporting the capture and use of patient-reported outcomes (PROs) at the point-of-care enriches information about important clinical and quality of life outcomes. Yet the ability to scale PROs across healthcare systems has been limited by knowledge gaps around how to manage the diversity of PRO uses and leverage health information technology. In this study, we report learnings and practice insights from UW Medicine's practice transformation efforts to incorporate patient voice into multiple areas of care.

METHODS

Using a participatory, action research approach, we engaged with UW Medicine clinical and administrative stakeholders experienced with PRO implementation to inventory PRO implementations across the health system, characterize common clinical uses for PROs, and develop recommendations for system-wide governance and implementation of PROs.

RESULTS

We identified a wide breadth of PRO implementations (n = 14) in practice and found that nearly half (47%) of employed PRO measures captured shared clinical domains (e.g., depression). We developed three vignettes (use cases) that illustrate how users interact with PROs, characterize common ways PRO implementations support clinical care across the health system (1) Preventive care, (2) Chronic/Specialty care, and (3) Surgical/Interventional care), and elucidate opportunities to enhance efficient PRO implementations through system-level standards and governance.

CONCLUSIONS

Practice transformation efforts increasingly require integration of the patient voice into clinical care, often through the use of PROs. Learnings from our work highlight the importance of proactively considering how PROs will be used across the layers of healthcare organizations to optimize the design and governance of PROs.

Empowering genomic medicine by establishing critical sequencing result data flows: the eMERGE example

The eMERGE Network is establishing methods for electronic transmittal of patient genetic test results from laboratories to healthcare providers across organizational boundaries. We surveyed the capabilities and needs of different network participants, established a common transfer format, and implemented transfer mechanisms based on this format. The interfaces we created are examples of the connectivity that must be instantiated before electronic genetic and genomic clinical decision support can be effectively built at the point of care. This work serves as a case example for both standards bodies and other organizations working to build the infrastructure required to provide better electronic clinical decision support for clinicians.

Designing Safer Use of Antipsychotics Among Youths: A Human-Centered Approach to an Algorithm-Based Solution

OBJECTIVE

Guidelines recommend against prescribing antipsychotics without an indication, yet prescription rates remain undesirably high for youths. Information technology can facilitate guideline-based prescribing, but little is known about providers' needs. The Safer Use of Antipsychotics in Youth project is implementing an algorithm-based workflow for peer consultation, care navigation, and expedited psychotherapy access. To optimize workflow for a multisite trial, we engaged providers for input.

METHODS

Guided by human-centered design, we interviewed 15 providers from Kaiser Permanente Washington and Nationwide Children's Hospital about their prescribing barriers and workflow preferences. We identified qualitative themes on barriers affecting implementation and design opportunities to optimize workflow.

RESULTS

Providers expressed two major barriers: potential disruptions to clinical practice and threats to professional autonomy. Three design opportunities emerged: à la carte orders, passive review of orders, and consultation self-acknowledgment.

CONCLUSIONS

Human-centered design offers an innovative approach to improve guideline-based prescribing with optimizations that are grounded in providers' needs.

Opportunities and challenges to advance the use of electronic patient-reported outcomes in clinical care: a report from AMIA workshop proceedings

Despite the demonstrated value of patient-centered care, health systems have been slow to integrate the patient’s voice into care delivery through patient-reported outcomes (PROs) with electronic tools. This is due in part to the complex interplay of technology, workflow, and human factors that shape the success of electronic PROs (ePROs) use. The 2018 American Medical Informatics Association Annual Symposium served as the setting for a half-day interactive workshop with diverse stakeholders to discuss proposed best practices for the planning, design, deployment, and evaluation of ePROs. We provide this collective commentary that synthesizes participant feedback regarding critical challenges that prohibit the scale and spread of ePROs across healthcare delivery systems, including governance and leadership, workflow and human factors, informatics, and data science. In order to realize the promise of ePROs at scale, adaptable approaches are critical to balance the needs of individual users with health systems at large.

A Closer Look at Health Information Seeking by Older Adults and Involved Family and Friends: Design Considerations for Health Information Technologies

Older adults are the largest consumers of healthcare. As part of a broader study of personal health information management (PHIM), we interviewed older adults in King County, Washington, and their involved family and friends (FF), regarding health information (HI) sources they seek and utilize. Analysis of interview transcripts revealed four main themes: 1) older adults and FF consider healthcare providers the foundational source of HI; 2) older adults utilize FF for seeking, sharing, and interpreting HI, while FF serve as surrogate seekers and experience-based experts; 3) online searching is common for older adults and FF, but confidence in assessing the quality of online HI is often lacking; 4) a smorgasbord approach is frequently utilized by older adults and FF for gathering and clarifying HI. Design considerations include: facilitating access to quality provider-vetted HI, incorporating older adults and FF in the design process, and creating shared spaces for communication of HI among older adults, FF, and providers.

Monitoring for change: the role of family and friends in helping older adults manage personal health information

Objective

Although family and friends (FF) often play a significant support role in the health of older adults (OA), we know little about their role in personal health information management (PHIM). To address this gap and inform the design of PHIM tools, we describe the work, needs, and barriers of FF in the context of PHIM for OAs.

Methods

We conducted semi-structured telephone interviews with 52 FF identified by OA as being important in their health and PHIM. We analyzed interview transcripts for themes about FF information work, barriers, and support needs.

Results

FF play a supportive role in OA health maintenance, medical encounters, decision making, and daily activities. Monitoring, the ongoing process of seeking information related to the OA status, emerged as a key activity comprised of 3 phases: detection, interpretation, and action. Barriers to monitoring included OA choices and constraints, FF constraints, and difficulty with technological tools, resources, health information exchange between providers, social network dynamics, and physical distance.

Conclusions

FF frequently monitor for change in OA well-being, seeking up-to-date information to facilitate support of OA PHIM. Health information technology tools designed for FF can support all phases of monitoring by providing: (1) timely and granular levels of access to OA health information as the OA ages; (2) tailored health education for FF that is based on OA clinical data; and (3) networking platforms that integrate delegation, volunteering, and relevant resources, along with tools to facilitate support of OA appointment calendars and medication management. Such tools could reduce the burden of PHIM for OA and their loved ones.

Roles and Functions of Community Health Workers in Primary Care

Community health workers have potential to enhance primary care access and quality, but remain underutilized. To provide guidance on their integration, we characterized roles and functions of community health workers in primary care through a literature review and synthesis. Analysis of 30 studies identified 12 functions (ie, care coordination, health coaching, social support, health assessment, resource linking, case management, medication management, remote care, follow-up, administration, health education, and literacy support) and 3 prominent roles representing clusters of functions: clinical services, community resource connections, and health education and coaching. We discuss implications for community health worker training and clinical support in primary care.

Eliciting Values of Patients with Multiple Chronic Conditions: Evaluation of a Patient-centered Framework

Patients with multiple chronic conditions often face competing demands for care, and they often do not agree with physicians on priorities for care. Patients ' values shape their healthcare priorities, but existing methods for eliciting values do not necessarily meet patients ' care planning needs. We developed a patient-centered values framework based on a field study with patients and caregivers. In this paper we report on a survey to evaluate how the framework generalizes beyond field study participants, and how well the framework supports values elicitation. We found that respondents frame values in a way that is consistent with the framework, and that domains of the framework can be used to elicit a breadth of potential values individuals with MCC express. These findings demonstrate how a patient-centered perspective on values can expand on the domains considered in values clarification methods andfacilitate patient-provider communication in establishing shared care priorities.

Emergency information management needs and practices of older adults: A descriptive study

OBJECTIVE

To better understand how older adults currently manage emergency information, the barriers and facilitators to planning and management of emergency information, as well as the potential role of information technology to facilitate emergency planning and management.

INTRODUCTION

Older adults face a much higher risk of sudden illness/injury and are the age group with the largest percentages of emergent and urgent healthcare visits. Emergency information (health information needed in an emergency situation such as emergency contact information, diagnoses, and advance directives) needs to be maintained and easily accessible to ensure older adults get appropriate care and treatment consistent with their wishes in emergency situations. Current health information technologies rarely take into consideration the emergency information needs of older adults, their caregivers, and emergency responders.

METHODS

As part of a larger study we performed in-depth interviews with 90 older adults living in a variety of residential settings (independent living, retirement communities, assisted living) regarding how they manage information about their health. Interview sessions included photos of important health information artifacts. Interviews were transcribed and coded.

RESULTS

Analysis of in-depth interviews revealed that emergency information is a type of health information that older adults frequently manage. Participants differed in whether they practice emergency planning (e.g. the preparation and continued management of emergency information), and in whether they involve others in emergency information and emergency planning. Despite its importance, emergency information was often not up-to-date and not always kept in locations readily apparent to emergency responders.

CONCLUSION

Emergency information, such as emergency contact information, diagnoses, and advance directives, is a type of health information that older adults manage. Considering emergency information in the design of health information technologies for older adults could address some of the barriers and support the facilitators to emergency planning and information management.

Understanding What Is Most Important to Individuals with Multiple Chronic Conditions: A Qualitative Study of Patients' Perspectives

BACKGROUND

To improve care for individuals living with multiple chronic conditions, patients and providers must align care planning with what is most important to patients in their daily lives. We have a limited understanding of how to effectively encourage communication about patients' personal values during clinical care.

OBJECTIVE

To identify what patients with multiple chronic conditions describe as most important to their well-being and health.

DESIGN

We interviewed individuals with multiple chronic conditions in their homes and analyzed results qualitatively, guided by grounded theory.

PARTICIPANTS

A total of 31 patients (mean age 68.7 years) participated in the study, 19 of which included the participation of family members. Participants were from Kaiser Permanente Washington, an integrated health care system in Washington state.

APPROACH

Qualitative analysis of home visits, which consisted of semi-structured interviews aided by photo elicitation.

KEY RESULTS

Analysis revealed six domains of what patients described as most important for their well-being and health: principles, relationships, emotions, activities, abilities, and possessions. Personal values were interrelated and rarely expressed as individual values in isolation.

CONCLUSIONS

The domains describe the range and types of personal values multimorbid older adults deem important to well-being and health. Understanding patients' personal values across these domains may be useful for providers when developing, sharing, and following up on care plans.

Healthcare provider education to support integration of pharmacogenomics in practice: the eMERGE Network experience

Ten organizations within the Electronic Medical Records and Genomics Network developed programs to implement pharmacogenomic sequencing and clinical decision support into clinical settings. Recognizing the importance of informed prescribers, a variety of strategies were used to incorporate provider education to support implementation. Education experiences with pharmacogenomics are described within the context of each organization's prior involvement, including the scope and scale of implementation specific to their Electronic Medical Records and Genomics projects. We describe common and distinct education strategies, provide exemplars and share challenges. Lessons learned inform future perspectives. Future pharmacogenomics clinical implementation initiatives need to include funding toward implementing provider education and evaluating outcomes.

Acceptability of a team-based mobile health (mHealth) application for lifestyle self-management in individuals with chronic illnesses

With increased incidence of chronic illnesses arising due to unhealthy lifestyle habits, it is increasingly important to leverage technology applications to promote and sustain health behavior change. We developed a smartphone-based application, NutriWalking (NW), which recommends personalized daily exercise goals and promotes healthy nutritional habits in small peer teams. Here, we demonstrate an early study of usability and acceptability of this app in patients with type 2 Diabetes Mellitus and Depression. Our goal was to evaluate the potential of NW as a self-management support tool. Findings point to design considerations for team-based self-management tools delivered via mHealth platforms.

Creating Conditions for Patients' Values to Emerge in Clinical Conversations: Perspectives of Health Care Team Members

Eliciting, understanding, and honoring patients' values- the things most important to them in daily life-is a cornerstone of patient-centered care. However, this rarely occurs explicitly as a routine part of clinical practice. This is particularly problematic for individuals with multiple chronic conditions (MCC) because they face difficult choices about how to balance competing demands for self-care in accordance with their values. In this study, we sought to inform the design of interventions to support conversations about patient values between patients with MCC and their health care providers. We conducted a field study that included observations of 21 clinic visits for patients who have MCC, and interviews with 16 care team members involved in those visits. This paper contributes a practice-based account of ways in which providers engage with patient values, and discusses how future work in interactive systems design might extend and enrich these engagements.

Understanding views on everyday use of personal health information: Insights from community dwelling older adults

BACKGROUND

Older adults apply various strategies to pursue healthy aging, but we know little about their views and use of personal health information to accomplish those ends.

METHODS

As a first step in formulating the role of personal health information management (PHIM) in healthy aging, we explored the perspectives of older adults on health and health information used in their everyday lives through four focus groups with 25 community-dwelling adults aged 60 and over.

RESULTS

We found that the concept of wellness-the holistic and multidimensional nature of health and wellbeing-plays prominently in how older adults think about health and health information. Participants expressed wellness from a position of personal strength, rather than health-related deficits, by focusing on wellness activities for staying healthy through: (1) personal health practices, (2) social network support, and (3) residential community engagement.

CONCLUSION

Although these themes involve personal health information, existing PHIM systems that focus on disease management are generally not designed to support wellness activities. Substantial opportunity exists to fill this wellness support gap with innovative health information technology designed for older adults. Findings carry implications for the design of PHIM tools that support healthy aging and methods for engaging older adults as co-producers of this critical support.

Acceptability of Fitbit for physical activity tracking within clinical care among men with prostate cancer

Prior research has not examined the acceptability of commercially available fitness tracking devices in men with prostate cancer, many of whom are at risk for conditions that physical activity could alleviate. We conducted an exploratory 3-week field study to examine acceptability of the Fitbit Zip and attitudes towards integrating fitness tracking into clinical care among men with prostate cancer. Twenty-six men used the Fitbit Zip for a one-week baseline phase followed by a 2-week optional use phase and then completed in-depth interviews. Interview data was analyzed using inductive thematic analysis. Participants found the device comfortable and easy to wear. Barriers to use included health and technology difficulties. Participants expressed value in sharing Fitbit data with their health care team. Findings support the use of easy to use and simple fitness trackers among men with prostate cancer and there could be opportunities to integrate fitness tracker data into clinical care.

Diagnosing Surgical Site Infection Using Wound Photography: A Scenario-Based Study

BACKGROUND

Postoperative surgical site infections (SSI) are common and costly. Most occur post discharge, and can result in potentially preventable readmission or unnecessary urgent evaluation. Mobile health approaches incorporating patient-generated wound photos are being implemented in an attempt to optimize triage and management. We assessed how adding wound photos to existing data sources modifies provider decision making.

STUDY DESIGN

We used a web-based simulation survey using a convenience sample of providers with expertise in surgical infections. Participants viewed a range of scenarios, including surgical history, physical exam, and description of wound appearance. All participants reported SSI diagnosis, diagnostic confidence, and management recommendations (main outcomes) first without, and then with, accompanying wound photos. At each step, participants ranked the most important features contributing to their decision.

RESULTS

Eighty-three participants completed a median of 5 scenarios (interquartile range 4 to 7). Most participants were physicians in academic surgical specialties (n = 70 [84%]). The addition of photos improved overall diagnostic accuracy from 67% to 76% (p < 0.001), and increased specificity from 77% to 92% (p < 0.001), but did not significantly increase sensitivity (55% to 65%; p = 0.16). Photos increased mean confidence in diagnosis from 5.9 of 10 to 7.4 of 10 (p < 0.001). Overtreatment recommendations decreased from 48% to 16% (p < 0.001), and undertreatment did not change (28% to 23%; p = 0.20) with the addition of photos.

CONCLUSIONS

The addition of wound photos to existing data as available via chart review and telephone consultation with patients significantly improved diagnostic accuracy and confidence, and prevented proposed overtreatment in scenarios without SSI. Post-discharge mobile health technologies have the potential to facilitate patient-centered care, decrease costs, and improve clinical outcomes.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Practical considerations for implementing genomic information resources. Experiences from eMERGE and CSER

OBJECTIVES

To understand opinions and perceptions on the state of information resources specifically targeted to genomics, and approaches to delivery in clinical practice.

METHODS

We conducted a survey of genomic content use and its clinical delivery from representatives across eight institutions in the electronic Medical Records and Genomics (eMERGE) network and two institutions in the Clinical Sequencing Exploratory Research (CSER) consortium in 2014.

RESULTS

Eleven responses representing distinct projects across ten sites showed heterogeneity in how content is being delivered, with provider-facing content primarily delivered via the electronic health record (EHR) (n=10), and paper/pamphlets as the leading mode for patient-facing content (n=9). There was general agreement (91%) that new content is needed for patients and providers specific to genomics, and that while aspects of this content could be shared across institutions there remain site-specific needs (73% in agreement).

CONCLUSION

This work identifies a need for the improved access to and expansion of information resources to support genomic medicine, and opportunities for content developers and EHR vendors to partner with institutions to develop needed resources, and streamline their use - such as a central content site in multiple modalities while implementing approaches to allow for site-specific customization.

"It just seems outside my health": How Patients with Chronic Conditions Perceive Communication Boundaries with Providers

To improve care for the growing number of older adults with multiple chronic conditions, physicians and other healthcare providers need to better understand what is most important in the lives of these patients. In a qualitative study of home visits with patients and family caregivers, we found that patients withhold information from providers when communicating about what they deem important to their health and well-being. We examine the various motivations and factors that explain communication boundaries between patients and their healthcare providers. Patients' disclosures reflected perceptions of what was pertinent to share, assumptions about the consequences of sharing, and the influence of interpersonal relationships with providers. Our findings revealed limitations of existing approaches to support patient-provider communication and identified challenges for the design of systems that honor patient needs and preferences.

A Prognostic Model of Surgical Site Infection Using Daily Clinical Wound Assessment

BACKGROUND

Surgical site infection (SSI) remains a common, costly, and morbid health care-associated infection. Early detection can improve outcomes, yet previous risk models consider only baseline risk factors (BF) not incorporating a proximate and timely data source-the wound itself. We hypothesize that incorporation of daily wound assessment improves the accuracy of SSI identification compared with traditional BF alone.

STUDY DESIGN

A prospective cohort of 1,000 post open abdominal surgery patients at an academic teaching hospital were examined daily for serial features (SF), for example, wound characteristics and vital signs, in addition to standard BF, for example, wound class. Using supervised machine learning, we trained 3 Naïve Bayes classifiers (BF, SF, and BF+SF) using patient data from 1 to 5 days before diagnosis to classify SSI on the following day. For comparison, we also created a simplified SF model that used logistic regression. Control patients without SSI were matched on 5 similar consecutive postoperative days to avoid confounding by length of stay. Accuracy, sensitivity/specificity, and area under the receiver operating characteristic curve were calculated on a training and hold-out testing set.

RESULTS

Of 851 patients, 19.4% had inpatient SSIs. Univariate analysis showed differences in C-reactive protein, surgery duration, and contamination, but no differences in American Society of Anesthesiologists scores, diabetes, or emergency surgery. The BF, SF, and BF+SF classifiers had area under the receiver operating characteristic curves of 0.67, 0.76, and 0.76, respectively. The best-performing classifier (SF) had optimal sensitivity of 0.80, specificity of 0.64, positive predictive value of 0.35, and negative predictive value of 0.93. Features most associated with subsequent SSI diagnosis were granulation degree, exudate amount, nasogastric tube presence, and heart rate.

CONCLUSIONS

Serial features provided moderate positive predictive value and high negative predictive value for early identification of SSI. Addition of baseline risk factors did not improve identification. Features of evolving wound infection are discernable before the day of diagnosis, based primarily on visual inspection.

Relevance of graph literacy in the development of patient-centered communication tools

OBJECTIVE

To determine the literacy skill sets of patients in the context of graphical interpretation of interactive dashboards.

METHODS

We assessed literacy characteristics of prostate cancer patients and assessed comprehension of quality of life dashboards. Health literacy, numeracy and graph literacy were assessed with validated tools. We divided patients into low vs. high numeracy and graph literacy. We report descriptive statistics on literacy, dashboard comprehension, and relationships between groups. We used correlation and multiple linear regressions to examine factors associated with dashboard comprehension.

RESULTS

Despite high health literacy in educated patients (78% college educated), there was variation in numeracy and graph literacy. Numeracy and graph literacy scores were correlated (r=0.37). In those with low literacy, graph literacy scores most strongly correlated with dashboard comprehension (r=0.59-0.90). On multivariate analysis, graph literacy was independently associated with dashboard comprehension, adjusting for age, education, and numeracy level.

CONCLUSIONS

Even among higher educated patients; variation in the ability to comprehend graphs exists.

PRACTICE IMPLICATIONS

Clinicians must be aware of these differential proficiencies when counseling patients. Tools for patient-centered communication that employ visual displays need to account for literacy capabilities to ensure that patients can effectively engage these resources.

Design Considerations for Smoking Cessation Apps: Feedback From Nicotine Dependence Treatment Providers and Smokers

Background

Hundreds of smoking cessation apps are commercially available, but most are not theory-based or designed to take advantage of mobile technology in ways that could make them more engaging and possibly more effective. Considering input from both clinical experts (who understand best practice nicotine dependence treatment requirements) to inform appropriate content and from smokers (the end users) to express their preferences is important in designing these programs in the future.

Objective

To assess and compare the opinions of nicotine dependence treatment providers and smokers regarding the design of future smoking cessation apps.

Methods

We surveyed providers (n=264) and smokers who own smartphones (n=40) to assess their opinions on the importance of 21 app design features. Features represented 5 domains: cost, reputation, privacy and security, content and user experience, and communication. Domains were chosen to reflect best practice treatment, leverage mobile technology to support smoking cessation, and elicit important user preferences. Data were collected between June and July 2015.

Results

Most providers agreed that mHealth apps hold promise for helping people quit smoking (203/264, 76.9%) and would recommend them to their clients/patients (201/264, 76.1%), especially if the app were empirically validated (236/264, 89.4%). Few providers believe effective cessation apps currently exist (112/264, 42.4%). Few smokers (5/40, 13%) had ever downloaded a smoking cessation app; of the ones who had not, most said they would consider doing so (29/35, 83%). Both respondent groups indicated the following features were very to extremely important to include in cessation apps: free or low cost, keeps information private, matches individual needs and interests, adapts as one’s needs and interests change, helps to manage nicotine withdrawal symptoms and medication side effects, and allows users to track their progress. Providers and smokers also indicated gaming and social media connectivity were less important than other features. Despite these similarities, the groups had significantly different opinions about the relative importance of various features. In particular, providers rated privacy as the most important feature, whereas smokers rated low cost and the ability to adaptively tailor content as the most important features.

Conclusions

Smoking cessation apps hold great promise as intervention tools but only if they engage users and appropriately treat nicotine dependence. Intervention development should take into consideration the perspectives of both treatment experts and smokers. This paper highlights important perspectives from each of these groups to be considered when designing future app-based smoking cessation programs.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Homophily of Vocabulary Usage: Beneficial Effects of Vocabulary Similarity on Online Health Communities Participation

Online health communities provide popular platforms for individuals to exchange psychosocial support and form ties. Although regular active participation (i.e., posting to interact with other members) in online health communities can provide important benefits, sustained active participation remains challenging for these communities. Leveraging previous literature on homophily (i.e., "love of those who are like themselves"), we examined the relationship between vocabulary similarity (i.e., homophily of word usage) of thread posts and members' future interaction in online health communities. We quantitatively measured vocabulary similarity by calculating, in a vector space model, cosine similarity between the original post and the first reply in 20,499 threads. Our findings across five online health communities suggest that vocabulary similarity is a significant predictor of members' future interaction in online health communities. These findings carry practical implications for facilitating and sustaining online community participation through beneficial effects of homophily in the vocabulary of essential peer support.