HIV Provider Documentation and Actions Following Patient Reports of At-risk Behaviors and Conditions When Identified by a Web-Based Point-of-Care Assessment.

We compared same-day provider medical record documentation and interventions addressing depression and risk behaviors before and after delivering point-of-care patient-reported outcomes (PROs) feedback for patients who self-reported clinically relevant levels of depression or risk behaviors. During the study period (1 January 2006-15 October 2010), 2289 PRO assessments were completed by HIV-infected patients. Comparing the 8 months before versus after feedback implementation, providers were more likely to document depression (74% before vs. 87% after feedback, p = 0.02) in patients with moderate-to-severe depression (n = 317 assessments), at-risk alcohol use (41 vs. 64%, p = 0.04, n = 155) and substance use (60 vs. 80%, p = 0.004, n = 212). Providers were less likely to incorrectly document good adherence among patients with inadequate adherence after feedback (42 vs. 24%, p = 0.02, n = 205). While PRO feedback of depression and adherence were followed by increased provider intervention, other domains were not. Further investigation of factors associated with the gap between awareness and intervention are needed in order to bridge this divide.

Mobile health applications to assist patients with diabetes: lessons learned and design implications.

Self-management is critical to achieving diabetes treatment goals. Mobile phones and Bluetooth® can supportself-management and lifestyle changes for chronic diseases such as diabetes. A mobile health (mHealth) research platform--the Few Touch Application (FTA)--is a tool designed to support the self-management of diabetes. The FTA consists of a mobile phone-based diabetes diary, which can be updated both manually from user input and automatically by wireless data transfer, and which provides personalized decision support for the achievement of personal health goals. Studies and applications (apps) based on FTAs have included: (1) automatic transfer of blood glucose (BG) data; (2) short message service (SMS)-based education for type 1diabetes (T1DM); (3) a diabetes diary for type 2 diabetes (T2DM); (4) integrating a patient diabetes diary with health care (HC) providers; (5) a diabetes diary for T1DM; (6) a food picture diary for T1DM; (7) physical activity monitoring for T2DM; (8) nutrition information for T2DM; (9) context sensitivity in mobile self-help tools; and (10) modeling of BG using mobile phones. We have analyzed the performance of these 10 FTA-based apps to identify lessons for designing the most effective mHealth apps. From each of the 10 apps of FTA, respectively, we conclude: (1) automatic BG data transfer is easy to use and provides reassurance; (2) SMS-based education facilitates parent-child communication in T1DM; (3) the T2DM mobile phone diary encourages reflection; (4) the mobile phone diary enhances discussion between patients and HC professionals; (5) the T1DM mobile phone diary is useful and motivational; (6) the T1DM mobile phone picture diary is useful in identifying treatment obstacles; (7) the step counter with automatic data transfer promotes motivation and increases physical activity in T2DM; (8) food information on a phone for T2DM should not be at a detailed level; (9) context sensitivity has good prospects and is possible to implement on today's phones; and (10) BG modeling on mobile phones is promising for motivated T1DM users. We expect that the following elements will be important in future FTA designs: (A) automatic data transfer when possible; (B) motivational and visual user interfaces; (C) apps with considerable health benefits in relation to the effort required; (D) dynamic usage, e.g., both personal and together with HC personnel, long-/short-term perspective; and (E) inclusion of context sensitivity in apps. We conclude that mHealth apps will empower patients to take a more active role in managing their own health.

Participatory (re)design of a sociotechnical healthcare delivery system: the Group Health Patient-Centered Medical Home.

This paper describes one organization's interpretation of the Patient-Centered Medical Home concept and the healthcare delivery system that has emerged from their participatory redesign initiative. Group Health, a large integrated healthcare system based in Seattle, Washington, USA initiated a Patient-Centered Medical Home care delivery system transformation in January 2007. Current theories and evidence about the Patient-Centered Medical Home (PCMH), the Chronic Care Model, and effective primary care were interpreted via a facilitated group process and translated into a core set of 5 system design principles. These design principles guided all subsequent system transformation activities. The central organizing principle is supporting and sustaining the patient-primary care physician relationship. The emergent PCMH healthcare delivery system comprises both opportunistic point-of-care and outreach components, many of which leverage and enhance the organization's health information and communication technologies.

Patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation.

BACKGROUND: A patient-centered medical home (PCMH) demonstration was undertaken at 1 healthcare system, with the goals of improving patient experience, lessening staff burnout, improving quality, and reducing downstream costs. Five design principles guided development of the PCMH changes to staffing, scheduling, point-of-care, outreach, and management. OBJECTIVE: To report differences in patient experience, staff burnout, quality, utilization, and costs in the first year of the PCMH demonstration. STUDY DESIGN: Prospective before and after evaluation. METHODS: Baseline (2006) and 12-month (2007) measures were compared. Patient and staff experiences were measured using surveys from a random sample of patients and all staff at the PCMH and 2 control clinics. Automated data were used to measure and compare change components, quality, utilization, and costs for PCMH enrollees versus enrollees at 19 other clinics. Analyses included multivariate regressions for the different outcomes to account for baseline case mix. RESULTS: After adjusting for baseline, PCMH patients reported higher ratings than controls on 6 of 7 patient experience scales. For staff burnout, 10% of PCMH staff reported high emotional exhaustion at 12 months compared with 30% of controls, despite similar rates at baseline. PCMH patients also had gains in composite quality between 1.2% and 1.6% greater than those of other patients. PCMH patients used more e-mail, phone, and specialist visits, but fewer emergency services. At 12 months, there were no significant differences in overall costs. CONCLUSIONS: A PCMH redesign can be associated with improvements in patient experience, clinician burnout, and quality without increasing overall cost.

Designing mobile dietary management support technologies for people with diabetes.

We performed two cycles of laboratory-based usability testing of three food registration prototypes for people with diabetes. The design concepts were a commercial web application, various smartphones and a mobile phone photo blogging approach. Six adults with Type 1 diabetes and three adults with Type 2 diabetes participated in the usability tests. The results provided five distinct implications for devices for the future dietary management support of people with diabetes. Study participants valued many of the features offered by the three systems that were tested, although the usability tests also revealed several opportunities to enhance their design. Our findings suggest that further development is justified of mobile dietary and nutritional support for individuals living with diabetes. Applications that support healthy eating habits should be integrated with applications for managing blood glucose data and physical activity data, and potentially medication data as well.

Providers' experience with an organizational redesign initiative to promote patient-centered access: a qualitative study.

BACKGROUND: Patient-centered access is a philosophy and a method that supports efforts to redesign health-care delivery systems to deliver higher quality care and to better meet the needs and preferences of patients. Since mid-2000, Group Health Cooperative has pursued an ensemble of strategic initiatives aimed at promoting patient-centered access, referred to as the Access Initiative. In support of this strategy, Group Health has also engaged in enterprise implementation of an electronic medical record and clinical information system that is integrated with their patient Web site, MyGroupHealth. OBJECTIVE: To elicit, describe, and characterize providers' perceptions of the effects of the Access Initiative, an information technology-enabled organizational redesign initiative intended to promote patient-centered access. DESIGN: Thematic analysis of semi-structured in-depth interviews. PARTICIPANTS: Twenty-two care providers representing 14 primary care, medical, and surgical specialties at Group Health Cooperative, an integrated health-care system based in Seattle, Washington. FINDINGS: Analyses of the interview transcripts revealed nine emergent themes, five of which have particular relevance for health-care organizations pursuing patient-centered access: the Access Initiative improved patient satisfaction, improved the quality of encounter-based care, compromised providers' focus on population health, created additional work for providers, and decreased job satisfaction for primary care providers and some medical specialists. CONCLUSIONS: Providers like that the Access Initiative is mostly good for their patients, but dislike the negative effects on their own quality of life - especially in primary care. These reforms may not be sustainable under current models of organization and financing.

Multidisciplinary eHealth survey evaluation methods.

This paper describes the development process of an evaluation framework for describing and comparing web survey tools. We believe that this approach will help shape the design, development, deployment, and evaluation of population-based health interventions. A conceptual framework for describing and evaluating web survey systems will enable the developers of health interventions to identify, select, and use the most appropriate and relevant survey tools. The primary contributors included survey methodologists, computer scientists, informaticians, technical communications specialists, educators, evaluators, clinical practitioners, and health services researchers, who together developed a comprehensive ontology to describe the electronic survey domain. This paper will describe the survey ontology development process and detail lessons learned in the creation of the web survey system evaluation framework.

Mobile eHealth interventions for obesity: a timely opportunity to leverage convergence trends.

Obesity is often cited as the most prevalent chronic health condition and highest priority public health problem in the United States. There is a limited but growing body of evidence suggesting that mobile eHealth behavioral interventions, if properly designed, may be effective in promoting and sustaining successful weight loss and weight maintenance behavior changes. This paper reviews the current literature on the successes and failures of public health, provider-administered, and self-managed behavioral health interventions for weight loss. The prevailing theories of health behavior change are discussed from the perspective of how this knowledge can serve as an evidence base to inform the design of mobile eHealth weight loss interventions. Tailored informational interventions, which, in recent years, have proven to be the most effective form of conventional health behavior intervention for weight loss, are discussed. Lessons learned from the success of conventional tailored informational interventions and the early successes of desktop computer-assisted self-help weight management interventions are presented, as are design principles suggested by Social Cognitive Theory and the Social Marketing Model. Relevant computing and communications technology convergence trends are also discussed. The recent trends in rapid advancement, convergence, and public adoption of Web-enabled cellular telephone and wireless personal digital assistant (PDA) devices provide timely opportunities to deliver the mass customization capabilities, reach, and interactivity required for the development, administration, and adoption of effective population-level eHealth tailored informational interventions for obesity.