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

ABSTRACT: BACKGROUND:Personal health records (PHRs) provide the opportunity for self-management support, enhancing communication between patients and caregivers, and maintaining and/or improving the quality of chronic disease management. Their implementation is a multi-level and complex process, requiring a holistic approach that takes into account the technology, its users and the context of implementation. The aim of this research is to evaluate the fidelity of a PHR in chronic care (the degree to which it was implemented as intended) in order to explain the found effects. METHODS:A convergent parallel mixed methods design was used, where qualitative and quantitative data were collected in parallel, analyzed separately, and finally merged. Log data of 536 users were used to gain insight into the actual long-term use of the PHR (the dose). Focus group meetings among caregivers (n?=?13) were conducted to assess program differentiation (or intended use). Interviews with caregivers (n?=?28) and usability tests with potential end-users (n?=?13) of the PHR were used to understand the responsiveness and the differences and similarities between the intended and actual use of the PHR. RESULTS:The results of the focus groups showed that services for coaching are strongly associated with monitoring health values and education. However, the PHR was not used that way during the study period. In the interviews, caregivers indicated that they were ignorant on how to deploy the PHR in current working routines. Therefore, they find it difficult to motivate their patients in using the PHR. Participants in the usability study indicate that they would value a PHR in the future, given that the usability will be improved and that the caregivers will use it in daily practice as well. CONCLUSIONS:In this study, actual use of the PHRs by patients was influenced by the responsiveness of caregivers. This responsiveness is likely to be strongly influenced by the perceived support when defining the differentiation and delivery of the PHR. A mixed-methods approach to understand intervention fidelity was of added value in providing explanations for the found effects that could not be revealed by solely focusing on the effectiveness of the technology in an experimental trial.

SUBMITTER: Sieverink F

PROVIDER: S-EPMC6882368 | biostudies-literature | 2019 Nov

REPOSITORIES: biostudies-literature

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

Sieverink Floor F Kelders Saskia S Braakman-Jansen Annemarie A van Gemert-Pijnen Julia J

BMC medical informatics and decision making 20191127 1

<h4>Background</h4>Personal health records (PHRs) provide the opportunity for self-management support, enhancing communication between patients and caregivers, and maintaining and/or improving the quality of chronic disease management. Their implementation is a multi-level and complex process, requiring a holistic approach that takes into account the technology, its users and the context of implementation. The aim of this research is to evaluate the fidelity of a PHR in chronic care (the degree ...[more]

PMID: 31775734

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Project description:BACKGROUND:The implementation of evidence-based interventions for borderline personality disorder in community settings is important given that individuals with this diagnosis are often extensive users of both inpatient and outpatient mental health services. Although work in this area is limited, previous studies have identified facilitators and barriers to successful DBT implementation. This study seeks to expand on previous work by evaluating a coordinated implementation of DBT in community settings at a national level. The Consolidated Framework for Implementation Research (CFIR) (Damschroder et al., Implementation Sci. 4:50, 2009) provided structural guidance for this national level coordinated implementation. METHODS:A mixed methods approach was utilised to explore the national multisite implementation of DBT from the perspective of team leaders and therapists who participated in the coordinated training and subsequent implementation of DBT. Qualitative interviews with DBT team leaders (n?=?8) explored their experiences of implementing DBT in their local service and was analysed using content analysis. Quantitative surveys from DBT therapists (n?=?74) examined their experience of multiple aspects of the implementation process including orienting the system, and preparations and support for implementation. Frequencies of responses were calculated. Written qualitative feedback was analysed using content analysis. RESULTS:Five themes were identified from the interview data: team formation, implementation preparation, client selection, service level challenges and team leader role. Participants identified team size and support for the team leader as key points for consideration in DBT implementation. Key challenges encountered were the lack of system support to facilitate phone coaching and a lack of allocated time to focus on DBT. Implementation facilitators included having dedicated team members and support from management. CONCLUSIONS:The barriers and facilitators identified in this study are broadly similar to those reported in previous research. Barriers and facilitators were identified across several domains of the CFIR and are consistent with a recently published DBT implementation Framework (Toms et al., Borderline Personal Disord Emot Dysregul. 6: 2, 2019). Future research should pay particular attention to the domain of characteristics of individuals involved in DBT implementation. The results highlight the importance of a mandated service plan for the coordinated implementation of an evidence-based treatment in a public health service. TRIAL REGISTRATION:ClinicalTrials.gov ID: NCT03180541; Registered June 7th 2017 'retrospectively registered'.

Project description:Demand is emerging for personal health records (PHRs), a patient-centric digital tool for engaging in shared decision-making and healthcare data management. This study uses a RE-AIM framework to explore rural patients and providers' perceptions prior to and following implementation of a PHR. Health care providers and their patients were recruited from early-adopter patient medical home clinics and a local patient advisory group. Focus groups were used to explore patient and provider pre-implementation perceptions of PHRs and post-implementation provider perspectives. Patients were invited through participating clinics to use the PHR. An implementation process evaluation was conducted. Multiple methods and data sources were used and included pre-/post-intervention patient surveys, provider interviews, and PHR/EHR administrative data. Both patient and provider focus groups described PHRs as providing a comprehensive health story and enhanced communication. Patients prioritized collection of health promotion data while providers endorsed health-related, clinical data. Both groups expressed the need for managing expectations and setting boundaries on PHR use. The evaluation indicated Reach: 16% of targeted patients participated and an additional 127 patients used the PHR as a tool during the COVID-19 pandemic. Effectiveness: Patient satisfaction with use was neutral, with no significant changes to quality of life, self-efficacy, or patients' activation. Adoption: 44% of eligible clinics participated, primarily those operated publicly versus privately, in smaller communities, and farther from a regional hospital. Implementation: Despite system interoperability expectations, at time of roll out, information exchange standards had not been reached. Additional implementation complications arose from the onset of the pandemic. One clinic on-boarded additional patients resulting in a rapid spike in PHR use. Maintenance: All clinics discontinued PHR within the study period, citing several key barriers to use. RE-AIM offers a valuable process evaluation framework for a comprehensive depiction of impact, and how to drive future success. Interoperability, patient agency and control, and provider training and support are critical obstacles to overcome in PHR implementation.

Project description:BackgroundWearable devices permit the continuous, unobtrusive collection of data from children in their natural environments and can transform our understanding of child development. Although the use of wearable devices has begun to emerge in research involving children, few studies have considered families' experiences and perspectives of participating in research of this kind.ObjectiveThrough a mixed methods approach, we assessed parents' and children's experiences of using a new wearable device in the home environment. The wearable device was designed specifically for use with infants and young children, and it integrates audio, electrocardiogram, and motion sensors.MethodsIn study 1, semistructured phone interviews were conducted with 42 parents of children aged 1 month to 9.5 years who completed 2 day-long recordings using the device, which the children wore on a specially designed shirt. In study 2, a total of 110 parents of children aged 2 months to 5.5 years responded to a questionnaire assessing their experience of completing 3 day-long device recordings in the home. Guided by the Digital Health Checklist, we assessed parental responses from both studies in relation to the following three key domains: (1) access and usability, (2) privacy, and (3) risks and benefits.ResultsIn study 1, most parents viewed the device as easy to use and safe and remote visits as convenient. Parents' views on privacy related to the audio recordings were more varied. The use of machine learning algorithms (vs human annotators) in the analysis of the audio data, the ability to stop recordings at any time, and the view that the recordings reflected ordinary family life were some reasons cited by parents who expressed minimal, if any, privacy concerns. Varied risks and benefits were also reported, including perceived child comfort or discomfort, the need to adjust routines to accommodate the study, the understanding gained from the study procedures, and the parent's and child's enjoyment of study participation. In study 2, parents' ratings on 5 close-ended items yielded a similar pattern of findings. Compared with a "neutral" rating, parents were significantly more likely to agree that (1) device instructions were helpful and clear (t109=-45.98; P<.001), (2) they felt comfortable putting the device on their child (t109=-22.22; P<.001), and (3) they felt their child was safe while wearing the device (t109=-34.48; P<.001). They were also less likely to worry about the audio recordings gathered by the device (t108=6.14; P<.001), whereas parents' rating of the burden of the study procedures did not differ significantly from a "neutral" rating (t109=-0.16; P=.87).ConclusionsOn the basis of parents' feedback, several concrete changes can be implemented to improve this new wearable platform and, ultimately, parents' and children's experiences of using child wearable devices in the home setting.

Project description:BackgroundPatients' perspectives and social contexts are critical for prevention of hospital readmissions; however, neither is routinely assessed using the traditional history and physical (H&P) examination nor commonly documented in the electronic health record (EHR). The H&P 360 is a revised H&P template that integrates routine assessment of patient perspectives and goals, mental health, and an expanded social history (behavioral health, social support, living environment and resources, function). Although the H&P 360 has shown promise in increasing psychosocial documentation in focused teaching contexts, its uptake and impact in routine clinical settings are unknown.ObjectiveThe aim of this study was to assess the feasibility, acceptability, and impact on care planning of implementing an inpatient H&P 360 template in the EHR for use by fourth-year medical students.MethodsA mixed methods study design was used. Fourth-year medical students on internal medicine subinternship (subI) services were given a brief training on the H&P 360 and access to EHR-based H&P 360 templates. Students not working in the intensive care unit (ICU) were asked to use the templates at least once per call cycle, whereas use by ICU students was elective. An EHR query was used to identify all H&P 360 and traditional H&P admission notes authored by non-ICU students at University of Chicago (UC) Medicine. Of these notes, all H&P 360 notes and a sample of traditional H&P notes were reviewed by two researchers for the presence of H&P 360 domains and impact on patient care. A postcourse survey was administered to query all students for their perspectives on the H&P 360.ResultsOf the 13 non-ICU subIs at UC Medicine, 6 (46%) used the H&P 360 templates at least once, which accounted for 14%-92% of their authored admission notes (median 56%). Content analysis was performed with 45 H&P 360 notes and 54 traditional H&P notes. Psychosocial documentation across all H&P 360 domains (patient perspectives and goals, mental health, expanded social history elements) was more common in H&P 360 compared with traditional notes. Related to impact on patient care, H&P 360 notes more commonly identified needs (20% H&P 360; 9% H&P) and described interdisciplinary coordination (78% H&P 360; 41% H&P). Of the 11 subIs completing surveys, the vast majority (n=10, 91%) felt the H&P 360 helped them understand patient goals and improved the patient-provider relationship. Most students (n=8, 73%) felt the H&P 360 took an appropriate amount of time.ConclusionsStudents who applied the H&P 360 using templated notes in the EHR found it feasible and helpful. These students wrote notes reflecting enhanced assessment of goals and perspectives for patient-engaged care and contextual factors important to preventing rehospitalization. Reasons some students did not use the templated H&P 360 should be examined in future studies. Uptake may be enhanced through earlier and repeated exposure and greater engagement by residents and attendings. Larger-scale implementation studies can help further elucidate the complexities of implementing nonbiomedical information within EHRs.

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Dataset Information

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

Publications

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

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