Simulating Telemedicine, Medication Reconciliation, and Social Determinants: A Novel Instructional Approach to Health Systems Competencies.

While medication reconciliation is necessary to reduce errors, it is often challenging to gather an accurate history in the clinic. Telemedicine offers a relative advantage over clinic and hospital-based interviews by enabling the clinician to inspect the home environment, review pill bottles, and identify social determinants affecting adherence, such as financial instability. To be effective, however, clinicians must be trained in best-practice interview methods and the proper use of telemedicine. There is very little information in the literature describing the best strategies for teaching students or measuring competencies in telemedicine. Therefore, we created an educational module with a telemedicine simulation and an evaluation rubric. We piloted this module with 48 medical and physician assistant students. Most students could complete a virtual interview and gather a medication history. However, only half identified an over-the-counter medication missing from the list. Most students were either entrustable or approaching entrustment in the six telemedicine competencies measured in this simulation. This simulation is valuable for teaching students about medication reconciliation, using telemedicine to close gaps in access to care, and identifying health-related social needs affecting medication adherence.

Identifying Failure Modes in Telemedicine: An Instructional Needs Assessment.

Technology failures in telehealth are common, and clinicians need the skills to diagnose and manage them at the point of care. However, there are issues beyond technology failures mediating the effective use of telehealth. We must teach best-practice procedures for conducting telemedicine visits and include in instructional simulations commonly encountered failure modes so students can build their skills. To this end, we recruited medical students to conduct a Healthcare Failure Modes and Effects Analysis (HFMEA) to predict failures in telemedicine, their potential causes, and the consequences to develop and teach prevention strategies. Sixteen students observed telehealth appointments independently. Based on their observations, we identified four categories of failures in telemedicine: technical issues, patient safety, communication, and social and structural determinants. We proposed a normalized workflow that included management and prevention strategies. Our findings can inform the creation of new curricula.

An Evaluation Guide and Decision Support Tool for Journey Maps in Healthcare and Beyond.

The journey map concept evolved out of the service design field and is still relatively new in the healthcare landscape [1]. Journey maps are visualizations that effectively highlight organizational issues and allow stakeholder groups to be depicted by interest or function for a comparative visual analysis [2]. There are five journey map approaches: 1) Mental (Cognitive) Model Map, 2) Customer Journey Map, 3) Experience Map, 4) Service Blueprint Map, 5) Spatial Map. The objective of this article is three-fold: 1) quantify and delineate the journey mapping visualization techniques utilized from the phase 1 scoping review [2], 2) create a Journey Map Evaluation Guide, 3) create a Journey Map Decision Support Tool to facilitate a standardized method for journey map selection. For those less familiar with journey mapping, this framework can serve as a decision-making tool to facilitate the most effective choice among the different journey mapping visualization approaches. The tools presented in this study can provide a mechanism to standardize the assessment, classification and utilization of journey maps in the healthcare sector and industries abound.

Contextualizing Online Laboratory (lab) Results and Mapping the Patient Journey.

The 21st century has brought forth unprecedented technological advances, such as the advent of portable digital devices [1]. This trend has also permeated the health care sector, with the introduction of digital health services, like providing citizens with access to their online laboratory (lab) results. This qualitative study will illustrate the patient journey, namely participant 16 (P16), to address the research question: what phases does a person go through when accessing their lab results online? The findings revealed that lab results were accessed from two types of devices a tablet (e.g., portable computer) when at home and a mobile phone when away from home. We also found that interpretation of results can be a challenge and it was unclear if P16 was able to understand her lab results. To illustrate the complexity of interpreting and accessing online lab results, the authors created a Customer Journey Map to contextualize the experiences of P16. The journey map depicts a combination of factors such as: eHealth literacy, limited access to providers, difficulty interpreting lab test results. Additionally, recommendations for online lab portal functionality enhancements were discovered through the mapping exercise. This study demonstrated that along with providing citizens with access to digital health technologies and services, considerations to eHealth literacy, the digital divide and health equity are paramount. As evidenced by the visualization, journey maps hold promise to serve as efficient tools to build empathy and identify the unique needs and perspectives of citizens.

Pre- and Post-Redesign Usability Assessment of a Telemedicine Interface Based on Subjective Metrics.

Usability problems in the interaction between patients and telemedicine platforms has been recognized as a deterrent in the public's acceptance and use of this alternative healthcare delivery method. Therefore, evaluating the usability of telemedicine provider websites, with a focus on potential patients' first interaction with telemedicine, is a critical research inquiry. To this end, a novel survey was developed to conduct an unmoderated remote usability test (URUT) of the Teladoc website. Teladoc is one of the largest providers of Direct-to-Consumer (DTC) telemedicine. The Teladoc Website Usability Survey (TWUS) instrument collected both objective task completion success metrics and subjective user feedback. A codebook was developed to categorize design features and user interface aspects that affected usability. The TWUS and codebook demonstrated value in identifying usability problems with the Teladoc interface and can be applied in other telemedicine or Health Information Technology (HIT) usability studies. Identifying and addressing usability issues is an important approach to increase the widespread acceptance and adoption of these healthcare delivery technologies.

A Telepsychiatry Simulation for Suicide Assessment: Teaching Telemedicine Safety Competencies.

Educators must provide controlled scenarios for health professional students to develop patient safety competencies related to telemedicine, including when and how to escalate care. We developed a telepsychiatry workshop to give students experience with a high-stakes mental health condition. The workshop included (1) pre-session readings; (2) didactics on mood disorders and telepsychiatry; (3) a motivational interviewing exercise; (4) a simulated telemedicine encounter; and (5) a faculty-led group debrief. We evaluated teaching effectiveness using a competency assessment with three scales: (1) medical knowledge; (2) interpersonal and communication skills; and (3) telemedicine competencies. Between 0 and 59% of students were entrustable for each telemedicine competency. Our workshop demonstrates how to teach students about the safe use of telehealth technology and provides practice triaging mental health conditions commonly encountered in primary care and mental health telemedicine clinics.

Student Academy: A Pilot Design Thinking Workshop to Teach Community Medicine.

The medical literature shows that social determinants of health have a significant impact upon health outcomes. However, health professionals often lack the skills to address these determinants at the systems-level. Therefore, we developed a Design Thinking workshop to teach about health-related social needs and to practice designing person-centered solutions. We piloted the workshop with 53 medical and physician assistant students; 69.8% responded to the post-workshop questionnaire. Nearly 80% of students agreed the workshop helped them understand the effect of context on clinical outcomes and demonstrated how to design patient-centered solutions. However, only 50% of respondents anticipated using the Design Thinking methods in their future practice. We need to identify more effective ways to demonstrate the practical application of Design Thinking to clinical work settings.

The Application of a Novel, Context Specific, Remote, Usability Assessment Tool to Conduct a Pre-Redesign and Post-Redesign Usability Comparison of a Telemedicine Website.

The usability of telemedicine provider websites is an essential component of increasing the public's awareness of, understanding of, and safe and effective use of telemedicine. A newly developed usability data collection tool was used to conduct a usability assessment of the Teladoc website pre- and post- a redesign. The results suggest that the Teladoc website had better usability prior to the redesign. The Teladoc Website Usability Survey (TWUS) developed for the Teladoc website usability assessment can be modified and used in future usability studies of telemedicine provider interfaces. Usability research that takes place in specific context of use settings is more valuable to identify usability problems.

Evidence-based Heuristics for Evaluating Demands on eHealth Literacy and Usability in a Mobile Consumer Health Application.

Heuristic evaluations have proven to be valuable for identifying usability issues in systems. Commonly used sets of heuritics exist; however, they may not always be the most suitable, given the specific goal of the analysis. One such example is seeking to evaluate the demands on eHealth literacy and usability of consumer health information systems. In this study, eight essential heuristics and three optional heuristics subsumed from the evidence on eHealth/health literacy and usability were tested for their utility in assessing a mobile blood pressure tracking application (app). This evaluation revealed a variety of ways the design of the app could both benefit and impede users with limited eHealth literacy. This study demonstrated the utility of a low-cost, single evaluation approach for identifying both eHealth literacy and usability issues based on existing evidence in the literature.

Integrating heuristic evaluation with cognitive walkthrough: development of a hybrid usability inspection method.

Developing more usable healthcare information systems has become an important goal in health informatics. Although methods from usability engineering have appeared and been effectively applied in the design and evaluation of healthcare systems, there continues to be reports of deployment of unusable systems and issues with adoption of healthcare IT worldwide. In this paper we propose a new cost-effective usability engineering approach for healthcare IT that integrates two of the major usability inspection approaches (heuristic evaluation and cognitive walkthrough) into one combined approach that leverages the advantages of both heuristic evaluation and cognitive walkthrough. The approach will be described as will a pilot application of the method in evaluating the usability of a well-known electronic health record system. Implications and future work will also be described.

Using personal health records to scaffold perceived self-efficacy for health promotion.

According to Bandura (1977), believing in one's ability to achieve a goal is one of the best predictors that a goal will be accomplished. Given its predictive power, the concept of belief in one's ability to succeed, or perceived self-efficacy, is well researched for its influence on health promotion. It has been argued that a paradigm shift must occur away from illness treatment towards illness prevention and health promotion, for healthcare to accommodate the needs of the population. Personal Health Records (PHRs) may be a tool to help facilitate this paradigm shift. PHRs are repositories of information that individuals can use to access, manage, and share their personal health information. An extension of Bandura's model of self-efficacy will be presented here which identifies opportunities for PHRs to enhance perceived self-efficacy through mastery, social modeling, social persuasion, and physiological state. Bolstering self-efficacy through PHR tools will expand the utility of PHRs beyond self-management to also facilitate health promotion and illness prevention and gains in self-efficacy are also likely to transcend into other areas of consumers' lives.