HeartCareII: patients' use of a home care web resource.

In a six-month randomized field experiment our team evaluated the impact of a technology-enhanced practice (TEP) model compared to the usual care delivered by home care nurses. Research staff provided computers and technical assistance; home care visit nurses trained patients in the use of the components of the HeartCareII website most relevant to their care needs. The purpose of this paper is to explore participant exposure to the web-based HeartCareII resources, the technical core of the TEP. To assess exposure to the HeartCareII resources we counted logins, the number of accesses to the system, over each participant's study period. We determined that more logins occurred during the first four weeks of the participants' time in the study, with 50 percent continuing to logon after 4 weeks. The number of participants accessing the system declined during the ensuing weeks to approximately one-third at eight weeks; almost 15 percent consistently logged in throughout their 24-week course in the experiment. This pattern of exposure to such web-based resources is consistent with findings of prior studies; it may support an episodic need for health resources in the home based on changing health demands.

Human factors and ergonomics in home care: Current concerns and future considerations for health information technology.

Sicker patients with greater care needs are being discharged to their homes to assume responsibility for their own care with fewer nurses available to aid them. This situation brings with it a host of human factors and ergonomic (HFE) concerns, both for the home care nurse and the home dwelling patient, that can affect quality of care and patient safety. Many of these concerns are related to the critical home care tasks of information access, communication, and patient self-monitoring and self-management. Currently, a variety of health information technologies (HITs) are being promoted as possible solutions to those problems, but those same technologies bring with them a new set of HFE concerns. This paper reviews the HFE considerations for information access, communication, and patients self-monitoring and self-management, discusses how HIT can potentially mitigate current problems, and explains how the design and implementation of HIT itself requires careful HFE attention.

Health@Home Moves All About the House!

It is now well recognized that patients play an important and active role in self-care and disease management, and many of these activities happen in their homes. Information technologies to support such care might be better used if they were designed taking into account the physical context of the home and the health information management needs of the residents. We conducted home-based interviews of 20 adults including an extensive analysis of their personal health information management (PHIM) tasks. Here we present these task descriptions, locations of their performance, and distribution across space and time. Implications for the informatics community include accommodating the distributed nature of tasks in the design of consumer technologies.

vizHOME--A context-based home assessment: Preliminary implications for informatics.

The rapid migration of health care from the institution to the home presents a plethora of consumer health technology options.. The fit of these technologies to the users' actual task performance and environment remains to be explored. In the vizHOME study, we set out to conduct in-depth analyses of health information management tasks conducted by individuals residing in 20 homes in the Midwestern United States who self-reported with diabetes. This paper will explore early results from five of the 13 assessments we have performed to-date. Early observations are described and implications for informatics are posited.

Project HealthDesign: a preliminary program-level report.

Advancements in the health information technology that brought personal health records to individuals have opened the door to new insights concerning the cues people use to monitor health in their everyday lives. In order to evaluate the impact of capturing, storing, and integrating these observations of daily living (ODLs) into the clinical care process, Project HealthDesign selected five teams to create and analyze mobile health applications with ODLs in mind. These teams targeted underserved, minority populations with at least two chronic conditions. Using third-party platforms for storage, the teams were expected to bring the ODLs into the clinical workflow through the EHR. ODLs were successfully captured, interpreted and displayed; however technical and policy barriers challenge their integration outside of the mobile application. This paper serves as a preliminary, program-level report distinct from the publication of evaluation results from individual teams.

Observations of daily living: putting the "personal" in personal health records.

Keeping individuals aware of their own health is a global challenge in health care. Observations of Daily Living (ODLs), cues to health that are derived from and personally meaningful to an individual, provide a detailed picture of one's experience of health. Project HealthDesign, an 8-year initiative of the Robert Wood Johnson Foundation, is investigating ODLs and devising innovative ways of tracking them through personal health record deployment in diverse communities and health care settings. Nursing informatics knowledge base and skills, applied to the ODL challenge can accelerate their identification, capture, and interpretation, thus empowering individuals toward meaningful action and facilitating more robust information exchange between individuals and their health care providers.

Technology-enhanced practice for patients with chronic cardiac disease: home implementation and evaluation.

OBJECTIVE: This 3-year field experiment engaged 60 nurses and 282 patients in the design and evaluation of an innovative home-care nursing model, referred to as technology-enhanced practice (TEP). METHODS: Nurses using TEP augmented the usual care with a web-based resource (HeartCareII) that provided patients with self-management information, self-monitoring tools, and messaging services. RESULTS: Patients exposed to TEP demonstrated better quality of life and self-management of chronic heart disease during the first 4 weeks, and were no more likely than patients in usual care to make unplanned visits to a clinician or hospital. Both groups demonstrated the same long-term symptom management and achievements in health status. CONCLUSION: This project provides new evidence that the purposeful creation of patient-tailored web resources within a hospital portal is possible; that nurses have difficulty with modifying their practice routines, even with a highly-tailored web resource; and that the benefits of this intervention are more discernable in the early postdischarge stages of care.

Designing study nurses' training to enhance research integrity: a macroergonomic approach.

Successful field evaluation of informatics initiatives designed to create technology-enhanced professional practice relies on adequate training of experimental participants. However, such training presents design, implementation and evaluation challenges. A macroergonomic approach, focusing on an organizational view of people, technology, task and environment interactions in work systems, provides a framework for training that allows anticipation and compensation for challenges. In the HeartCare II project, we developed a multi-level training program for nurses and patients enrolled in a field trial of an innovative technology-enhanced professional practice model. Using a macroergonomic approach, we designed three waves of training centered on a train-the-trainer model. Evaluation tools for each training wave provided improvement feedback. Despite planning, a drop-off occurred between training waves, affecting both recruitment and patient training. Troubleshooting identified people, task, technology, and organizational concerns. Strategies to increase nurse buy-in and improve technical performance are making a difference. Organizational challenges remain the most intractable.

Development of an instrument to measure technology acceptance among homecare patients with heart disease.

To monitor the experience of participants in a field evaluation of a home care Web support service we developed a survey to measure patient technology acceptance. Predictors of the acceptance model were selected from the technology acceptance literature. Cognitive interviewing was used to improve the validity of the survey items. We also describe the methods used to develop the survey.

Design and testing of an interactive smoking cessation intervention for inner-city women.

The purpose of this study was to design and test the usability of a computer-mediated smoking cessation program for inner-city women. Design and content were developed consistent with principles of user-centered design. Formative and summative evaluation strategies were utilized in its testing. The summative evaluation was designed to test usability in a naturalistic environment. A sample of 100 women who receive care at an inner-city community health center participated in the study. Average time for completing the computer program was 13.9 minutes. Participants reported a high level of satisfaction with usability of the program. Standardized instruments to measure cognitive processes of change related to smoking were completed at baseline and at 1 week. Participants reported a decrease in favorable attitudes toward smoking (P=0.014) and an increase in cognitive change processes at follow-up (P=0.037). These results indicate that interactive computer technology is acceptable to, and potentially useful for, promoting smoking cessation in low-income women.

Designing a technology enhanced practice for home nursing care of patients with congestive heart failure.

This paper describes the process we used to design the HeartCare website to support Technology Enhanced Practice (TEP) for home care nurses engaged in providing care for patients with Congestive Heart Failure (CHF). Composed of communication, information, and self-monitoring functions, the HeartCare website is aimed at supporting best practice nursing care for these patients. Its unique focus is professional practice, thus the scope of this project is greater and more abstract than those focusing on a task or set of activities. A modified macroergonomic analysis, design work system analysis, and focus groups utilizing participatory design methodology were undertaken to characterize the nursing practice model. Design of the HeartCare website required synthesizing the extant practice model and the agency's evidence-based heart failure protocols, identifying aspects of practice that could be enhanced by supporting technology, and delineation of functional requirements of the Enhanced HeartCare technology. Validation and refinement of the website and planning for user training activities will be accomplished through a two-stage usability testing strategy.

Usability testing and outcomes of an interactive computer program to promote smoking cessation in low income women.

The purpose of this study was to develop and test an interactive computer-mediated smoking cessation program for inner-city women. A non-probability sample of 100 women who receive care at an inner-city community health center in Indianapolis participated in the usability study. Women completed the computer program in the clinic following baseline data collection. Next, participants completed a brief satisfaction instrument. Data on cognitive and behavioral outcomes of the program were obtained by telephone interview one week later. Satisfaction with the program was high (mean satisfaction score was 60.2 with 70 indicating highest possible satisfaction). Average time for completing the computer program was 13.6 minutes. Overall, 79% of the participants reported at least one behavioral change related to smoking. The results indicate that interactive computer technology may be useful for promoting smoking cessation in low-income women.