Awakening and Breathing Coordination: A Mixed-Methods Analysis of Determinants of Implementation.

Rationale: Routine spontaneous awakening and breathing trial coordination (SAT/SBT) improves outcomes for mechanically ventilated patients, but adherence varies. Understanding barriers to and facilitators of consistent daily use of SAT/SBT (implementation determinants) can guide the development of implementation strategies to increase adherence to these evidence-based interventions. Objectives: We conducted an explanatory, sequential mixed-methods study to measure variation in the routine daily use of SAT/SBT and to identify implementation determinants that might explain variation in SAT/SBT use across 15 intensive care units (ICUs) in urban and rural locations within an integrated, community-based health system. Methods: We described the patient population and measured adherence to daily use of coordinated SAT/SBT from January to June 2021, selecting four sites with varied adherence levels for semistructured field interviews. We conducted key informant interviews with critical care nurses, respiratory therapists, and physicians/advanced practice clinicians (n = 55) from these four sites between October and December 2021 and performed content analysis to identify implementation determinants of SAT/SBT use. Results: The 15 sites had 1,901 ICU admissions receiving invasive mechanical ventilation (IMV) for ⩾24 hours during the measurement period. The mean IMV patient age was 58 years, and the median IMV duration was 5.3 days (interquartile range, 2.5-11.9). Coordinated SAT/SBT adherence (within 2 h) was estimated at 21% systemwide (site range, 9-68%). ICU clinicians were generally familiar with SAT/SBT but varied in their knowledge and beliefs about what constituted an evidence-based SAT/SBT. Clinicians reported that SAT/SBT coordination was difficult in the context of existing ICU workflows, and existing protocols did not explicitly define how coordination should be performed. The lack of an agreed-upon system-level measure for tracking daily use of SAT/SBT led to uncertainty regarding what constituted adherence. The effects of the COVID-19 pandemic increased clinician workloads, impacting performance. Conclusions: Coordinated SAT/SBT adherence varied substantially across 15 ICUs within an integrated, community-based health system. Implementation strategies that address barriers identified by this study, including knowledge deficits, challenges regarding workflow coordination, and the lack of performance measurement, should be tested in future hybrid implementation-effectiveness trials to increase adherence to daily use of coordinated SAT/SBT and minimize harm related to the prolonged use of mechanical ventilation and sedation.

Nurse, Parent, and Nurse Leader Perspective on Adoption of iPads for Pediatric Preoperative Anxiety Reduction.

PURPOSE: The purpose of this study was to examine the use of an iPad to facilitate distraction and reduce anxiety with preoperative pediatric patients. DESIGN: The authors conducted a descriptive case study in a Pre-Anesthesia Surgical Suite. METHODS: Nurses were trained on the use of the iPad, which came preloaded with games. The research staff took detailed notes during training and implementation. Research staff conducted interviews with nurses, leaders, and patient guardians for the study. FINDINGS: The authors discovered different perspectives among the clinical nurse, parent, and nursing leadership. The clinical nurse felt the iPad afforded them more focused time with the parents before surgery, though there was some hesitation at the beginning due to ownership of the devices. The parents felt the iPads were helpful to distract their child but worried there were not enough games appropriate for various age ranges. Nursing leadership found the iPads helpful in building a connection with the patient and their parents. Still, they felt many obstacles made integrating the use of the iPads in the nurses' workflow very difficult. There were technological issues that also delayed and discouraged the use of iPads. Once these preliminary issues were resolved, the iPad appeared to reduce anxiety in both patients and their parents. CONCLUSIONS: The iPad is an evidence-based intervention used for preoperative anxiety reduction. This study identifies essential facilitators and barriers associated with adopting the technology from the perspective of key stakeholders (nurses, parents, and nursing leadership). Overall, the iPad was considered a valuable tool to help parents feel less stressed with their child, allowing them to interact more effectively with the clinician. However, additional work is indicated to address the limitations regarding sample size and actual measures of anxiety.

Beyond Burnout and Resilience: The Disillusionment Phase of COVID-19.

In caring for patients during the COVID-19 pandemic, nurses are experiencing a crisis of emotional highs and lows that will have lasting implications for their professional and personal well-being. As a result, much attention has been focused on nurse burnout, but the range of nurses' experiences is more nuanced, complicated, and profound. With the recognition that the nursing workforce was already experiencing burnout before the pandemic, this article explores how individuals respond to disasters and the detrimental effects of the repeated surges of critically ill patients, which have led nurses to experience an extended period of disillusionment that includes secondary traumatic stress, cumulative grief, and moral distress. This article describes the range of psychological responses to the COVID-19 pandemic so that nurse leaders can better identify resources and interventions to support nurses.

The Importance of Understanding COVID-19: The Role of Knowledge in Promoting Adherence to Protective Behaviors.

Background: Past research suggests that knowledge supports- but strong illness expectations thwart- adoption of protective behaviors (e.g., handwashing). Strong illness expectations may place COVID-19 essential workers at risk. It is unclear, however, whether knowledge can moderate the negative effects of pessimistic illness expectations on protective behaviors. We test COVID-19 knowledge as a moderator of the effects of (1) pessimistic illness expectations and (2) essential worker status on adherence to protective behaviors. Methods: Participants (n = 350) completed measures of knowledge, illness expectations, and protective behaviors. We used chi-square tests to examine associations between variables and logistic regressions to test the moderation models predicting adherence (low, high) while controlling for demographics. Results: Knowledge, illness expectations, and adherence were significantly associated with each other (p < 0.05). Essential workers had stronger illness expectations and lower knowledge than did non-essential workers (p < 0.001). Logistic regressions showed a non-significant Worker Status × Knowledge interaction (p = 0.59) but a significant Knowledge × Illness Expectations interaction (p < 0.05) indicating that those with strong illness expectations and low knowledge were disproportionately at risk of failing to adhere to recommended behaviors. Conclusions: Knowledge promotes protective behaviors by buffering the negative effects of pessimistic illness expectations. Essential workers are more likely to have low levels of knowledge with strong illness expectations, suggesting that educational policies may be warranted.

Interdisciplinary Optimization of Admission Documentation: Reducing the Bloat.

Moving toward the electronic health record increases the quality of information gathered. However, nurses argue that the electronic health record is an added burden. The aim of this study was to evaluate the removal of duplicative or unnecessary fields and reordering fields on the admission form to increase documentation that is meaningful to the patient story. A team of approximately 60 interdisciplinary clinicians engaged in document review to evaluate the importance of each field and removal or modification based on those findings. After a review of the 251 fields, the authors reduced the form to 124 fields, and the percentage of unfields by 31%. After outlier removal, the average time to complete the admission form decreased by 2.88 minutes. The new form showed a reduction of 36.71% of the use of the free text advance directive. Additionally, nurses' perceptions of the form significantly improved from pretest to posttest in terms of satisfaction with the form, time to complete, usability and usefulness, question flow, and length of the form. This study shows that an interdisciplinary team can effectively work together to optimize the Adult Admission History Form, increasing the quality of documentation while reducing the time to complete.

Impact of nurse burnout on organizational and position turnover.

BACKGROUND: The National Academies of Medicine describes clinician burnout as a serious threat to organizational health, including employee turnover. PURPOSE: To determine the relationship between resilience, burnout, and organizational and position turnover. METHODS: We surveyed direct care nurses in three hospitals 1 year apart between 2018 and 2019; 1,688 nurses completed 3,135 surveys included in analysis. FINDINGS: Fifty-four percent of nurses in our sample suffer from moderate burnout, with emotional exhaustion scores increasing by 10% and cynicism scores increasing 19% after 1 year. The impact of burnout on organizational turnover was significant, with a 12% increase in a nurse leaving for each unit increase on the emotional exhaustion scale, though it was not a factor in position turnover. DISCUSSION: These findings contribute to the growing body of evidence of nurse burnout and support policies and programs for annual measurement of burnout, increased employee wellbeing support, and improved work environments.

Patient-Driven Diabetes Technologies: Sentiment and Personas of the #WeAreNotWaiting and #OpenAPS Movements.

BACKGROUND: Patients with diabetes have developed innovative do-it-yourself (DIY) methods for adapting existing medical devices to better fit individual needs. METHOD: A multiple method study used Symplur Analytics to analyze aggregated Twitter data of #WeAreNotWaiting and #OpenAPS tweets between 2014 and 2017 to examine DIY patient-led innovation. Conversation sentiment was examined between diabetes stakeholders to determine changes over time. Two hundred of the most shared photos were analyzed to understand visual representations of DIY patient-led innovations. Finally, discourse analysis was used to identify the personas who engage in DIY patient-led diabetes technologies activities and conversations on Twitter. RESULTS: A total of 7886 participants who generated 46 578 tweets were included. Sentiment analysis showed that 82%-85% of interactions around DIY patient-led innovation was positive among patient/caregiver and physician groups. Through photo analysis, five content themes emerged: (1) disseminating media and conference coverage, (2) showcasing devices, (3) celebrating connections, (4) providing instructions, and (5) celebrating accomplishments. Six personas emerged across the overlapping userbase: (1) fearless leaders, (2) loopers living it up, (3) parents on a mission, (4) the tech titans, (5) movement supporters, and (6) healthcare provider advocates. Personas had varying goals and behaviors within the community. CONCLUSIONS: #WeAreNotWaiting and #OpenAPS on Twitter reveal a fast-moving patient-led movement focused on DIY patient innovation that is further mobilized by an expanding and diverse userbase. Further research is indicated to bring technology savvy persons with diabetes into conversation with healthcare providers and researchers alike.

Continuous Glucose Monitoring in the Real World Using Photosurveillance of #Dexcom on Instagram: Exploratory Mixed Methods Study.

BACKGROUND: Individuals with diabetes are using social media as a method to share and gather information about their health via the diabetes online community. Infoveillance is one methodological approach to examine health care trends. However, infoveillance, while very effective in identifying many real-world health trends, may miss opportunities that use photographs as primary sources for data. We propose a new methodology, photosurveillance, in which photographs are analyzed to examine real-world trends. OBJECTIVE: The purpose of this research is to (1) assess the use of photosurveillance as a research method to examine real-world trends in diabetes and (2) report on real-world use of continuous glucose monitoring (CGM) on Instagram. METHODS: This exploratory mixed methods study examined all photographs posted on Instagram that were identified with the hashtag #dexcom over a 3-month period-December 2016 to February 2017. Photographs were coded by CGM location on the body. Original posts and corresponding comments were textually coded for length of CGM device wear and CGM failure and were analyzed for emerging themes. RESULTS: A total of 2923 photographs were manually screened; 12.08% (353/2923) depicted a photograph with a CGM site location. The majority (225/353, 63.7%) of the photographs showed a CGM site in an off-label location, while 26.2% (92/353) were in an FDA-approved location (ie, abdomen) and 10.2% (36/353) were in an unidentifiable location. There were no significant differences in the number of likes or comments based on US Food and Drug Administration (FDA) approval. Five themes emerged from the analysis of original posts (N=353) and corresponding comments (N=2364): (1) endorsement of CGM as providing a sense of well-being; (2) reciprocating information, encouragement, and support; (3) reciprocating CGM-related frustrations; (4) life hacks to optimize CGM use; and (5) sharing and learning about off-label CGM activity. CONCLUSIONS: Our results indicate that individuals successfully used CGM in off-label locations, posting photos of these areas with greater frequency than of the abdomen, with no indication of sensor failure. While these photographs only capture a snapshot in time, these posts can be used to inform providers and industry leaders of real-world trends in CGM use. Additionally, there were instances in which sensors were worn beyond the FDA-approved 7-day period; however, they represented the minority in this study.

State of the Science: A Scoping Review and Gap Analysis of Diabetes Online Communities.

BACKGROUND: Individuals with diabetes are using online resources to engage in diabetes online communities to find diabetes-related support and information. The benefits and consequences of DOC (diabetes online community) use are unclear. This scoping review aims to map existing research focused on organic DOCs in which individuals affected by diabetes are interacting with peers. METHOD: A scoping review was conducted to comprehensively report and synthesize relevant literature published prior to 2018. Attention was paid to variations in study design, DOC user and platform characteristics, and potential or actual benefits and consequences. RESULTS: Of the 14 486 titles identified, 47 articles met the inclusion criteria and were included in this scoping review. No overt definition of the DOC could be identified. Perceived or actual benefits associated with DOC use can be broadly categorized as clinical, behavioral, psychosocial and community outcomes. Perceived, potential, or actual consequences associated with DOC use were categorized as quality of information, risky behavior exploration, acute concerns, psychosocial, privacy, and inactivity. CONCLUSIONS: The results of this review strongly suggest DOC use is highly beneficial with relatively few negative consequences. DOC use is an emerging area of research and research gaps exist. Future research should seek to identify benefits and consequences to DOC use in experimental trials.

Development of the Intercultural Diabetes Online Community Research Council: Codesign and Social Media Processes.

BACKGROUND: This case study describes the formation of the Intercultural Diabetes Online Community Research council (iDOCr) and community advisory board (CAB) to engage the diabetes community and researchers in the codesign of community-based participatory research (CBPR) to examine online peer support in type 2 diabetes (T2D). METHOD: Social media engagement was the foundation for CBPR knowledge generation. During the project, the iDOCr council and CAB (n = 27) met quarterly via video conferencing and three times in person during national diabetes meetings. Data from four Twitter chats were used to explore the usefulness and utility of Twitter data to learn about concerns and priorities of the diabetes online community (DOC) and supported the evolution of iDOCr, the development of a research question and the design of a CBPR study. RESULTS: The iDOCr project (1) created a diverse CAB; (2) raised awareness of iDOCr and online peer support, which resulted in support and trust from key opinion leaders within the DOC to enable future partnerships for research and funding; (3) engaged with English- and Spanish-speaking DOC users through social media; and (4) designed a CBPR study supported by Twitter chat data analyses. CONCLUSIONS: Integrating the voice of people with diabetes (PWD) and the DOC in designing CBPR, through use of a CAB, ensures the most important and relevant research questions are asked. Additional research focused on online peer support may increase health care provider confidence in referring PWD to this low-cost and relatively accessible resource with the potential power to advance health.

Twitter Analysis of #OpenAPS DIY Artificial Pancreas Technology Use Suggests Improved A1C and Quality of Life.

BACKGROUND: Patient-driven innovation in diabetes management has resulted in a group of people with type 1 diabetes who choose to build and share knowledge around a do-it-yourself (DIY) open source artificial pancreas systems (OpenAPS). The purpose of this study was to examine Twitter data to understand how patients, caregivers, and care partners perceive OpenAPS, the personal and emotional ramifications of using OpenAPS, and the influence of OpenAPS on daily life. METHODS: Qualitative netnography was used to analyze #OpenAPS on Twitter over a two-year period. RESULTS: There were 328 patients, caregivers, and care partners who generated 3347 tweets. One overarching theme, OpenAPS changes lives, and five subthemes emerged from the data: (1) OpenAPS use suggests self-reported A1C and glucose variability improvement, (2) OpenAPS improves sense of diabetes burden and quality of life, (3) OpenAPS is perceived as safe, (4) patient/caregiver-provider interaction related to OpenAPS, and (5) technology adaptation for user needs. CONCLUSIONS: As users of a patient-driven technology, OpenAPS users are self-reporting improved A1C, day-to-day glucose levels, and quality of life. Safety features important to individuals with diabetes are perceived to be embedded into OpenAPS technology. Twitter analysis provides insight on a patient population driving an innovative solution to improve their quality of diabetes care.

Predicting Prediabetes Through Facebook Postings: Protocol for a Mixed-Methods Study.

BACKGROUND: The field of infodemiology uses health care trends found in public networks, such as social media, to track and quantify the spread of disease. Type 2 diabetes is on the rise worldwide, and social media may be useful in identifying prediabetes through behavior exhibited through social media platforms such as Facebook and thus in designing and administering early interventions and containing further progression of the disease. OBJECTIVE: This pilot study is designed to investigate the social media behavior of individuals with prediabetes, before and after diagnosis. Pre- and postdiagnosis Facebook content (posts) of such individuals will be used to create a taxonomy of prediabetes indicators and to identify themes and factors associated with an actual diagnosis of prediabetes. METHODS: This is a single-center exploratory retrospective study that examines 20 adults with prediabetes. The investigators will code Facebook posts 3 months before through 3 months after prediabetes diagnosis. Data will be analyzed using both qualitative content analysis methodology as well as quantitative methodology to characterize participants and compare their posts pre- and postdiagnosis. RESULTS: The project was funded for 2015-2018, and enrollment will be completed by the end of 2018. Data coding is currently under way and the first results are expected to be submitted for publication in 2019. Results will include both quantitative and qualitative data about participants and the similarities and differences between coded social media posts. CONCLUSIONS: This pilot study is the first step in creating a taxonomy of social media indicators for prediabetes. Such a taxonomy would provide a tool for researchers and health care professionals to use social media postings for identifying those at greater risk of having prediabetes. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/10720.

Building a Resilient Workforce: Promoting Joy in Clinical Care.

At Dignity Health, one of the nation's largest healthcare systems, we believe that all people deserve access to quality medical care regardless of their background, ethnicity, or circumstances. Healing is our calling, and "Hello humankindness" is our brand purpose, which supports our mission to deliver compassionate, high-quality, and affordable patient-centered care with special attention to the poor and underserved. Through teamwork and innovation, faith and compassion, and advocacy and action, we endeavor every day to keep our patients and staff members healthy and fulfilled. This article highlights efforts at Dignity Health to reduce burnout and increase resilience in our employees. Our team is focusing on evidence-based interventions and strategic partnerships to tackle these complicated issues.

Diabetes Online Community User Perceptions of Successful Aging With Diabetes: Analysis of a #DSMA Tweet Chat.

BACKGROUND: According to the American Diabetes Association, there are approximately 30.3 million Americans with diabetes, and the incidence is growing by nearly 1.5 million cases per year. These individuals are at particularly high risk of developing secondary comorbid conditions related to diabetes and aging. Nearly 45% of individuals aged 65 to 75 years use social media, and this number is steadily growing. The use of social media provides the opportunity to assess the perceptions and needs of this population. OBJECTIVE: The purpose of this study was to examine stakeholder perceptions of successful aging with diabetes. METHODS: This study presents a retrospective analysis of a tweet chat focused on aging with diabetes. Tweets were collected using Symplur Signals data analytics software (Symplur LLC) and analyzed for content analysis, sentiment, and participant demographics. Two authors reviewed discussion posts for accuracy of analysis. RESULTS: A total of 59 individuals participated in this tweet chat generating 494 tweets and nearly 2 million impressions. Most (36/59, 63%) tweet chat participants were people living with diabetes; 25% (14/59) were caregivers and advocates. Seven countries were represented in the conversation. A majority (352/494, 71.3%) of the tweets indicated positive sentiment related to aging with diabetes. Five major themes emerged from the qualitative analysis: (1) personal decline now and in the future, (2) limited access to treatment, (3) inability to provide self-care, (4) health care provider capacity to support aging with diabetes, and (5) life-long online peer health support to facilitate diabetes management. CONCLUSIONS: Individuals with diabetes are living longer and want to be supported with specialized care and access to technology that will allow them to successfully age. Aging- and diabetes-related changes may complicate diabetes management into old age. People with diabetes desire options including aging in place; therefore, special training for care partners and health care providers who care for older adults is needed.

Understanding Why Older Adults With Type 2 Diabetes Join Diabetes Online Communities: Semantic Network Analyses.

BACKGROUND: As individuals age, chronic health difficulties may disrupt physical and social well-being. Individuals can turn to online communities to interact with similar peers, which may help buffer negative effects resulting from health difficulties. OBJECTIVE: This study investigated the reasons that older adults join a diabetes online community to better understand the specific resources that are being sought. METHODS: We used semantic network analyses to categorize the reasons participants provided for joining a community during the sign-up process. RESULTS: The most frequent reasons for joining were to seek information about their health condition, to help with self-management of health difficulties, for feelings of informational and social support, and for having a community with whom to share. Women were more likely to go online for sharing and companionship as well as for information and social support reasons, whereas men were more likely to go online for general information and self-management reasons. CONCLUSIONS: This study shows the reasons older adults seek to join a diabetes online community: for increased information and support regarding chronic health difficulties. Practitioners may want to consider ways to promote access to online communities among their older patients as a source of health information and a resource to provide a sense of community.

A Systematic Review of Reviews Evaluating Technology-Enabled Diabetes Self-Management Education and Support.

BACKGROUND: Since the introduction of mobile phones, technology has been increasingly used to enable diabetes self-management education and support. This timely systematic review summarizes how currently available technology impacts outcomes for people living with diabetes. METHODS: A systematic review of high quality review articles and meta analyses focused on utilizing technology in diabetes self-management education and support services was conducted. Articles were included if published between January 2013 and January 2017. RESULTS: Twenty-five studies were included for analysis. The majority evaluated the use of mobile phones and secure messaging. Most studies described healthy eating, being active and metabolic monitoring as the predominant self-care behaviors evaluated. Eighteen of 25 reviews reported significant reduction in A1c as an outcome measure. Four key elements emerged as essential for improved A1c: (1) communication, (2) patient-generated health data, (3) education, and (4) feedback. CONCLUSION: Technology-enabled diabetes self-management solutions significantly improve A1c. The most effective interventions incorporated all the components of a technology-enabled self-management feedback loop that connected people with diabetes and their health care team using 2-way communication, analyzed patient-generated health data, tailored education, and individualized feedback. The evidence from this systematic review indicates that organizations, policy makers and payers should consider integrating these solutions in the design of diabetes self-management education and support services for population health and value-based care models. With the widespread adoption of mobile phones, digital health solutions that incorporate evidence-based, behaviorally designed interventions can improve the reach and access to diabetes self-management education and ongoing support.

Using Interactive Patient Engagement Technology in Clinical Practice: A Qualitative Assessment of Nurses' Perceptions.

BACKGROUND: Research has shown patients who are more engaged in their care are likely to have better health outcomes and reduced health care costs. Health care organizations are now focusing their efforts in finding ways to improve patient engagement. At the forefront of this movement are patient engagement technology systems. In this paper, these emerging systems are described as interactive patient engagement technologies (iPET). OBJECTIVE: The objective of this descriptive study was to gain an understanding of the perceptions of nurses who are integrating these iPET systems into their daily clinical practice. METHODS: The research team interviewed 38 nurses from 2 California-based hospitals using a focused rapid ethnographic evaluation methodology to gather data. RESULTS: The study participants reported that using iPET systems may enhance clinical nursing practice. The 4 key findings of iPET were that it (1) is effective for distraction therapy, (2) has functionality that affects both patients and nurses, (3) has implications for clinical practice, and (4) may require additional training to improve usage. CONCLUSIONS: With sufficient training on the iPET system, nurses believed they could use these technologies as an enhancement to their clinical practice. Additionally, nurses perceived these systems served as distraction therapy for patients. Initial findings suggest that iPET is beneficial, but more research is required to examine the usefulness of iPET systems in the inpatient settings.

e-Patients Perceptions of Using Personal Health Records for Self-management Support of Chronic Illness.

Chronic illness self-management is largely moving from healthcare professionals and into the hands of the patient. One tool that has been promoted to facilitate self-management support of chronic illness by policymakers, health advocates, providers, and consumers is the personal health record. Little is known about how consumers effectively use personal health records for self-management support and for productive patient-provider interactions. The purpose of this study was to learn from chronically ill engaged, experienced, and educated (e-patient) adults how and why they use personal health records for self-management support and productive patient-provider interactions. Eighteen purposively selected consumers were interviewed in two communities. Qualitative description methods were used, and we used a grounded theory approach to analyzing interview data, which was digitally recorded and transcribed verbatim. We identified four major thematic categories that capture the perceptions of the chronically ill using personal health records: (1) patient engagement and health self-management, (2) access to and control over personal health data, (3) promotion of productive communication, and (4) opportunities for training and education. Knowledge gained from the e-patient personal health record users suggest that making improvements to the portal system and providing education to consumers and providers will increase the utility among the experienced users and encourage new users to embrace adoption and use.

The eHealth Enhanced Chronic Care Model: a theory derivation approach.

BACKGROUND: Chronic illnesses are significant to individuals and costly to society. When systematically implemented, the well-established and tested Chronic Care Model (CCM) is shown to improve health outcomes for people with chronic conditions. Since the development of the original CCM, tremendous information management, communication, and technology advancements have been established. An opportunity exists to improve the time-honored CCM with clinically efficacious eHealth tools. OBJECTIVE: The first goal of this paper was to review research on eHealth tools that support self-management of chronic disease using the CCM. The second goal was to present a revised model, the eHealth Enhanced Chronic Care Model (eCCM), to show how eHealth tools can be used to increase efficiency of how patients manage their own chronic illnesses. METHODS: Using Theory Derivation processes, we identified a "parent theory", the Chronic Care Model, and conducted a thorough review of the literature using CINAHL, Medline, OVID, EMBASE PsychINFO, Science Direct, as well as government reports, industry reports, legislation using search terms "CCM or Chronic Care Model" AND "eHealth" or the specific identified components of eHealth. Additionally, "Chronic Illness Self-management support" AND "Technology" AND several identified eHealth tools were also used as search terms. We then used a review of the literature and specific components of the CCM to create the eCCM. RESULTS: We identified 260 papers at the intersection of technology, chronic disease self-management support, the CCM, and eHealth and organized a high-quality subset (n=95) using the components of CCM, self-management support, delivery system design, clinical decision support, and clinical information systems. In general, results showed that eHealth tools make important contributions to chronic care and the CCM but that the model requires modification in several key areas. Specifically, (1) eHealth education is critical for self-care, (2) eHealth support needs to be placed within the context of community and enhanced with the benefits of the eCommunity or virtual communities, and (3) a complete feedback loop is needed to assure productive technology-based interactions between the patient and provider. CONCLUSIONS: The revised model, eCCM, offers insight into the role of eHealth tools in self-management support for people with chronic conditions. Additional research and testing of the eCCM are the logical next steps.