Generating user-driven patient personas to support preventive health care activities of rural-living unattached patients.

Objective: This study created personas using quantitative segmentation and knowledge user enhancement to inform intervention and service design for rural patients to encourage preventive care uptake. Methods: This study comprised a cross-sectional survey of rural unattached patients and a co-design workshop for persona development. Cross-sectional survey data were analyzed for meaningful subgroups based on quartiles of preventive care completion. These quartiles informed "relevant user segments" grouped according to demographics (age, sex), length of unattachment, percentage of up-to-date preventive activities, health care visit frequency, preventive priorities, communication confidence with providers, and chronic health conditions, which were then used in the workshop to build the final personas. Results: 207 responses informed persona user segments, and five health care providers and 13 patients attended the workshop. The resulting four personas, included John (not up-to-date on preventive care activities), Terrance (few up-to-date preventive care activities), George (moderately up-to-date preventive care activities), and Anne (mostly up-to-date preventive care activities). Conclusion: Quantitative persona development with integrated knowledge user co-design/enhancement elevated and enriched final personas that achieved robust profiles for intervention design. Innovation: This project's use of a progressive methodology to build robust personas coupled with participant feedback on the co-design process offers a replicable approach for health researchers.

A cross-sectional study of the preventive health care activities of western Canadian rural-living patients unattached to primary care providers.

Prevention services, such as screening tests and vaccination, are underutilized, especially by rural populations and patients without a usual primary care provider. Little is known about the compounding impacts on preventive care of being unattached and living in a rural area and there has been no comprehensive exploration of this highly vulnerable population's prevention activities. The twofold purpose of this research was to examine rural unattached patients' prevention activity self-efficacy and completion and to explore their experiences accessing healthcare, including COVID-19 impacts. Two thirds of patients had been unattached for over one year, and over 20 % had been unattached for over 5 years; males experienced longer unattachment compared to females. Completion rates of prevention activities were relatively low, ranging from 5.9 % (alcohol screening) to 59 % (vision test). Most participants did not complete their prevention care activities in line with the Lifetime Prevention Schedule timeline: 65 % of participants had less than half of their activities up-to-date and only 6.7 % of participants were up to date on 75 % or more of their prevention activities. Participants with higher prevention self-efficacy scores were more likely to be up-to-date on associated prevention activities but the longer patients had been unattached, the fewer their up-to-date prevention activities. Patients expressed negative impacts of COVID-19 including walk-in clinics shutting down limiting access to care. These results suggest serious gaps in rural unattached patients' preventive care and highlight the need for support when they are without a usual primary care provider, which can be lengthy.

Has Virtual Care Arrived? A Survey of Rural Canadian Providers During the Early Stages of the COVID-19 Pandemic.

We investigated the uptake and perceptions of virtual care solutions by rural Canadian primary and specialist providers during the early phase (May-June 2020) of the COVID-19 pandemic. A web-based, cross-sectional survey of rural primary and specialty care providers examined types of virtual care platforms used (eg, phone, video), appointment length, experience and satisfaction with the solution used, plans for future use of virtual care, and patients' use of virtual care services. Targeted participants were actively-practicing providers in rural Western Canada who were emailed an invitation for the study and its survey link. Fifty-nine providers (26% response rate) completed the survey. During the pandemic, 78% of providers reported using virtual care for more than 60% of their appointments, while only 3% did so frequently pre-pandemic. Most providers used phone consultations, despite believing that video provided a better virtual visit. Key barriers included workflow interruptions, unique concerns about quality of care, remuneration and sustainability, or poor internet access and bandwidth for both providers and patients. The key opportunity noted was improved access to care. While most virtual care visits were not conducted using video technologies, overall virtual care resulted in high provider satisfaction, while not increasing workload. Virtual care will continue to play an important role in future rural care practice; however, sustainability will require both provider-level and system-level changes.

Empowering Patients Through Virtual Care Delivery: Qualitative Study With Micropractice Clinic Patients and Health Care Providers.

BACKGROUND: Prior to the wider adoption of digital health technologies during the COVID-19 pandemic, applications of virtual care were largely limited to specialist visits and remote care using telehealth (phone or video) applications. Data sharing approaches using tethered patient portals were mostly built around hospitals and larger care systems. These portals offer opportunities for improved communication, but despite a belief that care has improved, they have so far shown few outcome improvements beyond medication adherence. Less is known about use of virtual care and related tools in the outpatient context and particularly in rural community contexts. OBJECTIVE: This study aims to reflect on the opportunities and barriers for sustainable virtual care through an example of a digitally enabled rural micropractice, which has provided 10%-15% virtual care since 2016 and 70% virtual care since March 2020. METHODS: Three focus groups, 1 with providers (physician and medical office manager) and 2 with a total of 8 patients from a rural micropractice in British Columbia, were conducted in November 2020 and December 2020. Virtual care delivery was explored through the topics of communication approach, mixing virtual and in-person care, the practice team's journey in developing these approaches, and provider and patient satisfaction with the care model. Interviews were transcribed, checked for accuracy against recordings, and thematically analyzed. RESULTS: Both patients and providers reported ease of communication and high satisfaction. Either could initiate communication, and patients found the ability to share health information asynchronously through the portal allowed time to reflect and prepare their thoughts. Patients were highly engaged and reported feeling empowered and true partners in their health care, although they noted limited care coordination with specialists. The mix of virtual and in-person visits was highly regarded by patients and providers, and patients reported feeling safe and cared for 24/7, although both expressed concern about work spilling into the provider's home life. The physician worried about missed diagnoses with virtual care. With respect to establishing the micropractice, solutions took about 5 years to optimize, with providers noting a learning curve requiring technical support for both themselves and their patients and a willingness to respond to patient feedback to identify the best solutions. Despite a mature virtual practice, patients reported deferred care due to COVID-19. CONCLUSIONS: The micropractice's hybrid care model encouraged patients to be true partners in their care and resulted in high patient engagement and satisfaction; yet, success may rely on the patient population being willing to engage and being comfortable with technology. Barriers lie in gaps in care coordination and provider fear that signs or symptoms more evident with an in-person exam could be missed. Even in this setting, deferral of care in light of COVID-19 was present, and opportunities to address care gaps should be sought.

Paving the Way for Electronic Patient-Centered Measurement in Team-Based Primary Care: Integrated Knowledge Translation Approach.

BACKGROUND: Patient-centered measurement (PCM) aims to improve the overall quality of care through the collection and sharing of patient values, outcomes, and perspectives. However, the use of PCM in care team decisions remains limited. Integrated knowledge translation (IKT) offers a collaborative, adaptive approach to explore best practices for incorporating PCM into primary care practices by involving knowledge users, including patients and providers, in the exploratory process. OBJECTIVE: This study aims to test the feasibility of using patient-generated data in team-based care; describe the use of these data for team-based mental health care; and summarize patient and provider care experiences with PCM. METHODS: We conducted a multi-method exploratory study in a rural team-based primary care clinic using IKT to co-design, implement, and evaluate the use of PCM in team-based mental health care. Care pathways, workflows, and quality improvement activities were adjusted iteratively to improve integration efforts. Patient and provider experiences were evaluated using individual interviews relating to the use of PCM and patient portals in practice. All meeting notes, interview summaries, and emails were analyzed to create a narrative evaluation. RESULTS: During co-design, a care workflow was developed to incorporate electronically collected patient-generated data from the patient portal into the electronic medical record, and customized educational tools and resources were added. During implementation, care pathways and patient workflows for PCM were developed. Patients found portal use easy, educational, and validating, but data entries were not used during care visits. Providers saw the portal as extra work, and the lack of portal and electronic medical record integration was a major barrier. The IKT approach was invaluable for addressing workflow changes and understanding the ongoing barriers to PCM use and quality improvement. CONCLUSIONS: Although the culture toward using PCM is changing, the use of PCM during care has not been successful. Patients felt validated and supported through portal use and could be empowered to bring these data to their visits. Training, modeling, and adaptable PCM methods are required before PCM can be integrated into routine care.

Advancing digital patient-centered measurement methods for team-based care.

Objectives: To conceptualize new methods for integrating patient-centered measurement into team-based care. Methods: A standalone portal was introduced into a rural clinic to support conceptualization of new methods for integration of patient-centered measurement in team-based care. The portal housed mental health-related online resources, three patient-reported measures and a self-action plan. Six providers and four patients used the portal for four months. Our data collection techniques included clinic discussions, one-on-one interviews, workflow diagrams and data generated through the portal. Analysis was supported through coding interview transcripts, looking across multiple sources of research data and research team discussions. Results: Our research team conceptualized five team-based patient-centered measurement methods through this study. Patient-centered measurement Team Mapping offfers a technique to provide greater clarity of care-team roles and responsibilities in data collected through patient-centered measurement. Longitudinal Care Alignment can guide the care-team on incorporating patient-centered measurement into ongoing provider-patient interactions. Digital Tool Exploration can be used to evaluate a team's readiness toward digital tool adoption, and the impact of these tools. Team-based quality improvement serves as a framework for engaging teams in patient-centered quality improvement. Shared learning is a method that promotes patientprovider interactions that validate patient's perspectives of their care. Conclusion: The portal illuminated new methods for the integration of patient-centered measurement in team-based care. The first three proposed patient-centered measurement methods provides ways to assess how a clinic can incorporate patient-centered measurement methods into team-based care. The latter two methods focus on the aim of patient-generated data in which patient's values and perspectives are represented and quality of patient-centered care can be evaluated. Further testing is needed to assess the utility of these patient-centered measurement methods across different clinical settings and domains.

Preferred Functions of Personal Health Records in Rural Primary Health Clinics in Canada: Health Care Team Perspectives.

BACKGROUND: Personal health records (PHR) provide opportunities for improved patient engagement, collection of patient-generated data, and overcome health-system inefficiencies. While PHR use is increasing, uptake in rural populations is lower than in urban areas. OBJECTIVES: The study aimed to identify priorities for PHR functionality and gain insights into meaning, value, and use of patient-generated data for rural primary care providers. METHODS: We performed PHR preimplementation focus groups with rural providers and their health care teams from five primary care clinics in a sparsely populated mountainous region of British Columbia, Canada to obtain their understanding of PHR functionality, needs, and perceived challenges. RESULTS: Eight general practitioners (GP), five medical office assistants, two nurse practitioners (NP), and two registered nurses (14 females and 3 males) participated in focus groups held at their respective clinics. Providers (GPs, NPs, and RNs) had been practicing for a median of 9.5 (range = 1-38) years and had used an electronic medical record for 7.0 (1-20) years. Participants expressed interest in incorporating functionality around two-way communication and appointment scheduling, previsit data gathering, patient and provider data sharing, virtual care including visits using videoconferencing tools, and postvisit sharing of educational materials. Three further themes emerged from the focus groups: (1) the context in which the providers' practice matters, (2) the need for providing patients and providers with choice (e.g., which data to share, who gets to initiate/respond in communications, and processes around virtual care visits), and (3) perceived risks of system use (e.g., increased complexity for older patients and workload barriers for the health care team). CONCLUSION: Rural primary care teams perceived PHR opportunities for increased patient engagement and access to patient-generated data, while worries about changes in workflow were the biggest perceived risk. Recommendations for PHR adoption in a rural primary health network include setting provider-patient expectations about response times, ability to share notes selectively, and automatically augmented note-taking from virtual-care visits.

Civilian Forensic Technician and Sworn Police Officer Job-Related Stress.

Forensic Technicians provide crime scene investigation services and are exposed to stressful violent crimes, motor vehicle accidents, biological or chemical hazards, and other appalling imagery. Forensic Technicians would likely experience physical and psychological stress after exposure to trauma, and security vulnerabilities similar to Sworn Police Officers. The perceived availability of mental health resources, job-related physical, psychological stress, and traumatic experiences of both Forensic Technicians and Sworn Police Officers from California law enforcement agencies were investigated using a self-reported survey. Responses were evaluated for any significant differences in the perceived stress, job-related physical stress, and resulting psychological impact affecting the participants. The survey contained a mix of True/False, Circle/Check the Appropriate Box, or Likert Scale (1-5) responses. The results were evaluated statistically and discussed. Results indicated Sworn Police Officers and Forensic Technicians have different on-duty stress levels, but similar off-duty stress levels. Nearly two-thirds of 54 job-related stressors were not significantly different between the two occupations. However, Forensic Technicians reported more adverse effects in 17 physical and psychological job-related activities compared with Sworn Police Officers. Forensic Technicians reported lower awareness levels and availability of agency mental health support services than were reported by Sworn Police Officers. This study reports for the first time an unexpected outcome that perceived and job-related psychological stress is greater for Forensic Technicians than Sworn Police Officers. Possible reasons for this disparity will be discussed as well as stress management tools that should be implemented to reduce health risk factors for both career professionals as well as increase public safety.

Moving Beyond the Rhetoric of Shared Decision-Making: Designing Personal Health Record Technology With Young Adults With Type 1 Diabetes.

OBJECTIVES: Engaging young adults with type 1 diabetes (T1D) in the self-management of daily tasks and decision-making provides opportunities for positive health outcomes. However, emerging adulthood and care transitions are associated with decreased clinic attendance and diabetes complications. Shared decision-making (SDM) is an optimal approach for health decisions; however, it has been difficult to implement in practice. Personal health record (PHR) technology is a promising approach for overcoming such barriers. Still, today, PHRs have yet to root themselves into care and present an opportunity for improvement in SDM and engagement in self-management decision-making. The objective of this study was to confirm a functional model of an integrated shared decision-making-personal health record system (e-PHR) by young adults with T1D and care providers. METHODS: User-centred design approach whereby young adults with T1D, 18 to 24 years of age, and care providers matched PHR functions for the SDM process to confirm an e-PHR functional model. RESULTS: An e-PHR functional model justified by young adults (n=7) and providers (n=15) was confirmed. The conceptual design was architected within an interconnected digital health ecosystem and integrated 23 PHR functionalities for SDM with a moderate level of agreement between patients and providers (Cohen kappa 0.60 to 0.74). CONCLUSIONS: The establishment of an e-PHR functional model is a precursor to system design requirements. Results highlight the conceivable value of integrating SDM into PHRs for engagement of young adults with T1D in self-management decision-making. Design implications highlight key challenges for future research and system development, including information exchange across disparate systems, usability considerations and system intelligence for information personalization and decision-support tools.

Ready for Prime Time? Using Normalization Process Theory to Evaluate Implementation Success of Personal Health Records Designed for Decision Making.

Personal health records designed for shared decision making (SDM) have the potential to engage patients and provide opportunities for positive health outcomes. Given the limited number of published interventions that become normal practice, this preimplementation evaluation of an integrated SDM personal health record system (e-PHR) was underpinned by Normalization Process Theory (NPT). The theory provides a framework to analyze cognitive and behavioral mechanisms known to influence implementation success. A mixed-methods investigation was utilized to explain the work required to implement e-PHR and its potential to integrate into practice. Patients, care providers, and electronic health record (EHR) and clinical leaders (n = 27) offered a rich explanation of the implementation work. Reliability tests of the NPT-based instrument negated the use of scores for two of the four mechanisms. Participants indicated that e-PHR made sense as explained by two qualitative themes: game-changing technology and sensibility of change. Participants appraised e-PHR as explained by two themes: reflecting on value and monitoring and adapting. The combined qualitative and quantitative results for the other two NPT mechanisms corroborated. Participants strongly agreed (score = 4.6/5) with processes requiring an investment in commitment, explained by two themes: sharing ownership of the work and enabling involvement. Weak agreement (score = 3.6/5) was observed with processes requiring an investment in effort, explained by one theme: uncovering the challenge of building collective action, and three subthemes: assessing fit, adapting to change together, and investing in the change. Finally, participants strongly agreed (score = 4.5/5) that e-PHR would positively affect engagement in self-management decision-making in two themes: care is efficient, and care is patient-centered. Overall, successful integration of e-PHR will only be attained when systemic effort is invested to enact it. Additional investigation is needed to explore the collective action gaps to inform priorities and approaches for future implementation success. This research has implications for patients, care providers, EHR vendors, and the healthcare system for improving the effectiveness and efficiency of patient-centric services. Findings confirm the usefulness of NPT for planning and understanding implementation success of PHRs.

Patient Health Information Technology Designed for Shared Decision Making: If We Implement It, Will It Become Normal Clinical Practice?

Personal health records designed for shared decision making have the potential to engage patients in self-management decision making. This pre-implementation evaluation was underpinned by Normalization Process Theory and utilized mixed methods to describe the cognitive and behavioral work of implementation, and its potential to integrate into practice. Participants invest in sense-making, commitment and appraisal processes with strong agreement for positive impact on engagement. Future implementation success will depend on a systemic investment of collective action.

Shared Decision Making via Personal Health Record Technology for Routine Use of Diabetic Youth: A Study Protocol.

Engaging patients in the self-management decision-making provides opportunities for positive health outcomes. The process of shared decision making (SDM) is touted as the pinnacle of patient-centred care, yet it has been difficult to implement in practice. Access to tools resulting from the integration of all health data and clinical evidence, and an ease of communications with care providers are needed to engage patients in decision making. Personal health record (PHR) technology is a promising approach for overcoming such barriers. Yet there is a scarcity of studies on system design for SDM via PHR. This paper describes a study protocol to identify functional requirements of PHR for facilitating SDM and factors that would influence the embedding of the proposed system in clinical practice.

Shared decision-making using personal health record technology: a scoping review at the crossroads.

OBJECTIVE: This scoping review aims to determine the size and scope of the published literature on shared decision-making (SDM) using personal health record (PHR) technology and to map the literature in terms of system design and outcomes. MATERIALS AND METHODS: Literature from Medline, Google Scholar, Cumulative Index to Nursing and Allied Health Literature, Engineering Village, and Web of Science (2005-2015) using the search terms "personal health records," "shared decision making," "patient-provider communication," "decision aid," and "decision support" was included. Articles ( n = 38) addressed the efficacy or effectiveness of PHRs for SDM in engaging patients in self-care and decision-making or ways patients can be supported in SDM via PHR. RESULTS: Analysis resulted in an integrated SDM-PHR conceptual framework. An increased interest in SDM via PHR is apparent, with 55% of articles published within last 3 years. Sixty percent of the literature originates from the United States. Twenty-six articles address a particular clinical condition, with 10 focused on diabetes, and one-third offer empirical evidence of patient outcomes. The tethered and standalone PHR architectural types were most studied, while the interconnected PHR type was the focus of more recently published methodological approaches and discussion articles. DISCUSSION: The study reveals a scarcity of rigorous research on SDM via PHR. Research has focused on one or a few of the SDM elements and not on the intended complete process. CONCLUSION: Just as PHR technology designed on an interconnected architecture has the potential to facilitate SDM, integrating the SDM process into PHR technology has the potential to drive PHR value.

Designing Personal Health Record Technology for Shared Decision Making.

Engaging patients in the self-management decision-making provides opportunities for positive health outcomes. The process of shared decision-making (SDM) is touted as the pinnacle of patient-centred care, yet it has been difficult to implement in practice. Access to tools resulting from the integration of all health data and clinical evidence, and an ease of communications with care providers are needed to engage patients in self management decision-making. Personal health record (PHR) technology is a promising approach for overcoming such barriers. Yet there is a scarcity of studies on system design for SDM via PHR. This paper describes the design and implications of a system for SDM via PHR.

A compositional personalization approach for designing personalized patient educational interventions for cardiovascular risk management.

Providing patients with personalized educational messages can improve self-management of Cardiovascular Disease (CVD) risk factors. We present our compositional personalization approach that generates personalized educational material by dynamically selecting fine-grained information snippets, as per the patient profile, and then synthesizing them in a educational template to yield personalized patient education interventions. We apply our personalization approach in the PULSE system--Personalization Using Linkages of SCORE and behavior change readiness to web-based Education--that generates personalized patient education for CVD risk management. The PULSE framework involves the calculation of CVD risk assessment using the Systematic COronary Risk Evaluation (SCORE) algorithm, the estimation of readiness to change using the Transtheoretical Model (TTM) of intentional behavior change. The educational interventions were derived from evidence-based staged lifestyle modification materials and Canadian guidelines for CVD risk management.

Personalized cardiovascular risk management linking SCORE and behaviour change to Web-based education.

The PULSE (Personalization Using Linkages of SCORE and behaviour change readiness to web-based Education) project objectives are to generate and evaluate a web-based personalized educational intervention for the management of cardiovascular risk. The program is based on a patient profile generated by combining: (a) an electronic patient data capture template (DCT); (b) the Systematic COronary Risk Evaluation (SCORE) algorithm; and (c) a Stage of Change determination model. The DCT inherently contains a set of evidence-based parameters for patient description and disease evaluation. The patient's stage of behaviour change determines messages consistent with the individual's change processes, decisional balance, and self-efficacy. The interventions are designed to address both medical and psychosocial aspects of risk management and, as such, we combine staged lifestyle modification materials and non-staged messages based on Canadian clinical guidelines to motivate personal risk management. The personalization decision logic is represented in Medical Logic Modules implemented in Java. An intelligent interactive system generates the personally relevant materials and delivers the education to the patient via the Web. An evaluation study will be conducted to determine whether web-based personalized educational strategies exert favourable influence on patient's interest, knowledge, and perceived compliance to the suggested lifestyle modifications.