An integrative review of chronic illness mHealth self-care interventions: Mapping technology features to patient outcomes.

Mobile health (mHealth)-hand-held technologies to address health priorities-has significant potential to answer the growing need for patient chronic illness self-care interventions. Previous reviews examined mHealth effect on patient outcomes. None have a detailed examination and mapping of specific technology features to targeted health outcomes. Examine recent chronic illness mHealth self-care interventions; map the study descriptors, mHealth technology features, and study outcomes. (1) Information extracted from PubMed, CINAHL, and Web of Science databases for clinical outcomes studies published 2010-January 2020; and (2) realist synthesis techniques for within and across case analysis. From 652 records, 32 studies were examined. Median study duration was 19.5 weeks. Median sample size was 62 participants. About 47% of interventions used solely patient input versus digital input; 50% sent tailored messages versus generic messages; 22% augmented the intervention with human interaction. Studies with positive clinical outcomes had higher use of digital input. Software descriptions were lacking. Most studies built interventions: only two incorporated target audience participation in development. We recommend researchers provide sufficient system description detail. Future research includes: data input characteristics; impact of augmentation with human interaction on outcomes; and development decisions.

Planning the Episode: Home Care Admission Nurse Decision-Making Regarding the Patient Visit Pattern.

During home health care (HHC) admissions, nurses provide input into decisions regarding the skilled nursing visit frequency and episode duration. This important clinical decision can impact patient outcomes including hospitalization. Episode duration has recently gained greater importance due to the Centers for Medicare and Medicaid Services (CMS) decrease in reimbursable episode length from 60 to 30 days. We examined admissions nurses' visit pattern decision-making and whether it is influenced by documentation available before and during the first home visit, agency standards, other disciplines being scheduled, and electronic health record (EHR) use. This observational mixed-methods study included admission document analysis, structured interviews, and a think-aloud protocol with 18 nurses from 3 diverse HHC agencies (6 at each) admitting 2 patients each (36 patients). Findings show that prior to entering the home, nurses had an information deficit; they either did not predict the patient's visit frequency and episode duration or stated them based on experience with similar patients. Following patient interaction in the home, nurses were able to make this decision. Completion of documentation using the EHR did not appear to influence visit pattern decisions. Patient condition and insurance restrictions were influential on both frequency and duration. Given the information deficit at admission, and the delay in visit pattern decision making, we offer health information technology recommendations on electronic communication of structured information, and EHR documentation and decision support.

Transitions of Care: Completeness of the Interoperability Data Standard for Communication from Home Health Care to Primary Care.

Data sharing is necessary to address communication deficits along the transitions of care among community settings. Evidence-based practice supports home healthcare (HHC) patients to see their primary care team within the first two weeks of hospital discharge to reduce rehospitalization risk. A small subset of patient data collected at HHC admission is mandated to be transmitted to primary care, predominantly by fax. Using qualitative analysis, we assessed completeness of the United States Core Data for Interoperability (USCDI) interoperability standard, as compared to the patient data collected by the primary care team (topics) and HHC (classes) during the initial visit; and offer interoperability recommendations. Findings indicate the USCDI does not cover 74% of the 19 faxed HHC classes that mapped to the primary care topics, and 95% of the 38 not-faxed HHC classes. We offer USCDI recommendations to address these interoperability gaps.

Getting to Complete and Accurate Medication Lists During the Transition to Home Health Care.

OBJECTIVES: Characterize the work that home health care (HHC) admission nurses complete as part of the medication reconciliation tasks, explore the impact of shared electronic medication data (interoperability) from the referral source on medication reconciliation, and highlight opportunities to enhance medication reconciliation with respect to transition in care to HHC agencies. DESIGN: Observational field study. SETTINGS AND PARTICIPANTS: Three diverse Pennsylvania HHC agencies; each used different electronic health record systems with different interoperability characteristics. Six nurses per site admitted 2 patients each (36 patients total). METHODS: Researchers observed the admission process in the patient home and at the HHC agency. The nurses' tasks related to medication reconciliation were characterized by (1) number and change types (ie, medications dropped or added; changes to dose, frequency/administration time, or tablet types) made to the referrer medication list during and after the home visit, and (2) reasons that the nurse called the health provider (doctor, pharmacy) to resolve medication-related issues. Differences between interoperable and non-interoperable observations were explored. RESULTS: Polypharmacy (on average, study patients were taking more than 12 medications) and high-risk medications (on average, more than 8 per patient) were pervasive. For 91% of patients, the number of medications decreased between pre- and post-reconciliation medication lists; 41% of the medications required changes. Nurses using interoperable systems needed to make fewer changes than nurses using non-interoperable systems. In two-thirds of observations, the nurse called a provider. CONCLUSIONS AND IMPLICATIONS: Changes to the referrer medication list and calls to providers highlighted the nurses' effort to complete the medication reconciliation. Interoperability appeared to reduce the number of changes required, but did not eliminate changes or calls to providers. We highlight opportunities to enhance medication reconciliation with respect to transition in care to HHC agencies.

There's a Problem With the Problem List: Incongruence of Patient Problem Information Across the Home Care Admission.

OBJECTIVES: Illustrate patterns of patient problem information received and documented across the home health care (HHC) admission process and offer practice, policy, and health information technology recommendations to improve information transfer. DESIGN: Observational field study. SETTING AND PARTICIPANTS: Three diverse HHC agencies using different commercial point-of-care electronic health records (EHRs). Six nurses per agency each admitted 2 patients (36 total). METHODS: Researchers observed the admission process and photographed documents and EHR screens across 3 phases: referral, assessment, and plan of care (POC). To create a standardized data set, we mapped terms within medical diagnoses, signs, symptoms, and Problems to 5 of the 42 Omaha System Problem Classification Scheme problem terms. This created 180 problem pattern cases (5 problem patterns per patient). RESULTS: Each pattern of problem information being present or absent was observed. In 52 cases (28.9%), a problem did not appear. In 36 cases (20%), the problem appeared in all 3 phases. In 46 cases (25.6%), the problem appeared in referral and/or assessment phases and not on the POC. Conversely, in 37 cases (20.5%), the problem appeared in referral or assessment phases and on the POC. In 9 cases (5%), the problem only appeared on the POC. Within the EHRs, there were no rationale fields to clarify including Problems or not and no problem status fields to identify active, resolved, or potential ones. CONCLUSIONS AND IMPLICATIONS: Diagnosis or problem information transferred from the referral source or gathered during an in-home assessment did not appear in the POC. Because of the EHR structure, clinicians could not identify inactive problem or problem priority. Documentation or mapping of a structured problem list using a standardized interprofessional terminology such as the Omaha System coupled with identification of rationale could support the documentation of problem status and priority and reduce information loss.

An integrative review and theoretical examination of chronic illness mHealth studies using the Middle-Range Theory of Self-care of Chronic Illness.

Self-management, or self-care, by individuals and/or families is a critical element in chronic illness management as more care shifts to the home setting. Mobile device-enhanced health care, or mHealth, is being touted as a means to support self-care. Previous mHealth reviews examined the effect of mHealth on patient outcomes, however, none used a theoretical lens to examine the interventions themselves. The aims of this integrative review were to examine recent (e.g., last 10 years) chronic illness mHealth empiric studies and (1) categorize self-care behaviors engaged in the intervention according to the Middle-Range Theory of Self-care of Chronic Illness, and (2) conduct an analysis of gaps in self-care theory domains and behaviors utilized. Methods included: (1) Best practice study identification, collection, and data extraction procedures and (2) realist synthesis techniques for within and across case analysis. From a pool of 652 records, 33 primarily North American clinical trials, published between 2010 and 2019 were examined. Most mHealth interventions used apps, clinician contact, and behavioral prompts with some wireless devices. Examination found self-care maintenance behaviors were supported in most (n = 30) trials whereas self-care monitoring (n = 12) and self-care management behaviors (n = 8) were less so. Few trials (n = 2) targeted all three domains. Investigation of specific behaviors uncovered an overexamination of physical activity and diet behaviors and an underexamination of equally important behaviors. By examining chronic illness mHealth interventions using a theoretical lens we have categorized current interventions, conducted a gap analysis uncovering areas for future study, and made recommendations to move the science forward.

Incorporating home healthcare nurses' admission information needs to inform data standards.

OBJECTIVE: Patient transitions into home health care (HHC) often occur without the transfer of information needed for critical clinical decisions and the plan of care. Owing to a lack of universally implemented standards, there is wide variation in information transfer. We sought to characterize missing information at HHC admission. MATERIALS AND METHODS: We conducted a mixed methods study with 3 diverse HHC agencies. Focus groups with nurses at each agency identified what information supports patient care decisions at admission. Thirty-six in-home admissions with associated documentation review determined the available information. To inform information standards development for the HHC admission process, we compared the types of information desired and available to an international standard for transitions in care information, the Continuity of Care Document (CCD) enhanced with Office of the National Coordinator for Healthcare Information Technology summary terms (CCD/S). RESULTS: Three-quarters of the items from the focus groups mapped to the CCD/S. Regarding available information at admission, no observation included all CCD/S data items. While medication information was needed and often available for 4 important decisions, concepts related to patient medication self-management appeared in neither the CCD/S nor the admission documentation. DISCUSSION: The CCD/S mostly met HHC nurses' information needs and is recommended to begin to fill the current information gap. Electronic health record recommendations include use of a data standard: the CCD or the proposed, more parsimonious U.S. Core Data for Interoperability. CONCLUSIONS: Referral source and HHC agency adoption of data standards is recommended to support structured, consistent data and information sharing.

Availability and Quality of Information Used by Nurses While Admitting Patients to a Rural Home Health Care Agency.

Home health care admission nurses need high quality patient information but that information is not uniformly available. Despite this challenge, these nurses must make four critical decisions at patient admission to construct the plan of care: (1) patient problems to address in the home health care episode; (2) patient medication management; (3) services in addition to skilled nursing; and (4) skilled nursing visit pattern. We observed 12 in-home admissions at a rural home health care agency and interviewed nurses before and after about these decisions. We analyzed content and quality of documents. To evaluate quality, for each decision we assessed concordance between documents. Interview responses provided context in the analysis. Across all admissions, documents and their contents were not uniformly present. Nurses rarely received visit pattern or medication management information. There was discordance in the number of patient problems among and between available documents and the plan of care. Electronic health record design recommendations include interoperability and structured, consistent, actionable information.

Incongruence of Patient Problem Information Across Three Phases of Home Care Admission: There's a Problem with the Problem List.

In home health care, the patient problem list is an important component of the admission and care planning processes and determines the subsequent care received. We examined the information received from the referring facilities and its relationship with the final patient problem list generated at home health care admission. Researchers observed 12 admissions and collected available documents related to the admission and care planning process. Problems identified in documents provided to admission nurses (input documents) and in documents subsequently created by those nurses (output documents) were coded to form a standardized set of problem terms across the documents. Documents available, distribution of problems within the documents, and concordance between input and output documents were assessed. A varying number of the 17 unique problems found across the documents were distributed by document type. Patients were referred to home health care with more clinical problems than were documented in the output documents.

Impact of Home Care Admission Nurses' Goals on Electronic Health Record Documentation Strategies at the Point of Care.

Home care nurses have multiple goals at the patient admission visit. Electronic health records support some of these goals, including high-quality documentation, but nurses may not complete the electronic documentation at the point of care. To characterize admission nurses' practices at the point of care and lay the foundation for design recommendations, this study investigates admission nurses' documentation strategies with respect to entering electronic data and how nursing goals affect them. We conducted 10 observations of home care agency admissions with five admission nurses in rural Pennsylvania. We collected screenshots and recorded the admission process. We asked the nurses questions outside the point of care. We coded the nurses' strategies at the data-entry screen level. Using thematic analysis, we investigated the influence of nursing goals on documentation strategies. Subject matter experts reviewed our findings. Several goals affect nurses' documentation strategies: ensure data accuracy, reduce time in the patient's home, and prevent infection. Home care admission nurses distribute the electronic documentation temporally due to their goals. Nurses developed memory aids to support completion of the documentation after leaving the patients' homes. Design and training should support the distributed manner in which home care nurses document patient encounters.

Knowledge Elicitation of Homecare Admission Decision Making Processes via Focus Group, Member Checking and Data Visualization.

Researchers elicit knowledge related to expert decision-making processes to inform information technology design and related interventions. However, in healthcare, many subject matter experts have limited time for such endeavors. In addition, researchers need to analyze voluminous amounts of qualitative data. Thus, we present a data collection and validation methodology: an initial focus group followed by targeted member checking, both supported by data visualization. We ground the work in a homecare admission case study. We conducted a focus group with six homecare admitting nurses at a rural agency. Our custom visualizations of the qualitative results helped to identify potential missing information. We conducted a member checking session with five nurses to validate the focus group results and to address the missing data. The member checking results were incorporated into the custom visualizations. The data collection and validation methodology shows promise for knowledge elicitation in time-constrained situations.

Data Visualization of Home Care Admission Nurses' Decision-Making.

The hospital to home care admission process is when nurses make important decisions about the post-transition episode, including medication reconciliation, plan of care, future visit patterns, and the inclusion of other disciplines. It is not clear how nurses get and use information to support decision-making. We conducted a focus group case study with six admitting home health nurses at a rural agency in Pennsylvania. We analyzed the data using thematic analysis and using our enhanced custom high level node-link diagram that highlights the relationships between decisions, tasks and information themes and sub-themes. The visualizations will be evaluated via review with home care subject matter experts.

Health Information Technology Evaluation Framework (HITREF) Comprehensiveness as Assessed in Electronic Point-of-Care Documentation Systems Evaluations.

We assessed the Health Information Technology (HIT) Reference-based Evaluation Framework (HITREF) comprehensiveness in two HIT evaluations in settings different from that in which the HITREF was developed. Clinician satisfaction themes that emerged from clinician interviews in the home care and the hospital studies were compared to the framework components. Across both studies, respondents commented on 12 of the 20 HITREF components within 5 of the 6 HITREF concepts. No new components emerged that were missing from the HITREF providing evidence that the HITREF is a comprehensive framework. HITREF use in a range of HIT evaluations by researchers new to the HITREF demonstrates that it can be used as intended. Therefore, we continue to recommend the HITREF as a comprehensive, research-based HIT evaluation framework to increase the capacity of informatics evaluators' use of best practice and evidence-based practice to support the credibility of their findings for fulfilling the purpose of program evaluation.

Opportunities in interdisciplinary care team adoption of electronic point-of-care documentation systems.

We conducted three evaluation studies in community and hospital settings to examine point-of-care documentation system adoption among interdisciplinary care team clinicians. In the community settings, quantitative methods included documentation time-to-completion and a clinician satisfaction survey. Qualitative methods included observations and follow-up interviews. Qualitative data and quantitative data were merged comparing findings along themes. In the hospitals, qualitative scenario testing results indicated clinician system adoption was universal, though not always timely. At all sites, mismatch between system functionality and workflow was a barrier to clinician system access during patient care and reduced clinician efficiency. Clinicians at all settings were satisfied with their ability to access other clinicians' notes, without increased interdisciplinary team communication. Clinicians did not identify any systems impact on patient outcomes. To facilitate adoption, clinicians should see the value of using the system as intended by receiving system data feedback that shows improvement of patient care and patient safety.

Challenges and facilitators to adoption of a point-of-care electronic health record in home care.

Electronic health records (EHRs), intended to improve the clinical process, are understudied in home care. The researchers assessed clinician satisfaction, informed by workflow and patient outcomes, to identify EHR adoption challenges. The mixed methods study setting was a Philadelphia agency with 137 clinicians. Adoption challenges included: (a) hardware problems coupled with lack of field support; (b) inadequate training; and (c) mismatch of EHR usability/functionality and workflow resulting in decreased efficiency. Adoption facilitators were support for team communication and improved clinical data timeliness. Opportunities for improved adoption included sharing with front-line clinicians EHR data related to patient care and health outcomes.

Challenges and facilitators to nurse use of a guideline-based nursing information system: recommendations for nurse executives.

AIMS: The aims of this study were to develop empirical data on how nurses used an evidenced-based nursing information system (NIS) and to identify challenges and facilitators to NIS adoption for nurse leaders. BACKGROUND: The NIS was part of the electronic health record with 200 evidence-based, interdisciplinary clinical practice guidelines from which clinicians selected to guide the patient's care. METHODS: A purposeful sample of 12 randomly selected nurses in three units across two hospitals participated in scenario-testing. Sessions were audio-recorded, transcribed, content analyzed, and coded for themes. RESULTS: Major themes emerged: computer placement in patient rooms; difficulty using NIS; documentation completeness; efficiency; time spent at the bedside; team communication; training; unintended consequences of workflow changes; perceived NIS value as challenge to adoption. CONCLUSIONS: Nurse executives' opportunities to improve adoption include enhancing communication to/from front-line clinicians about the hospitals' goals, perceived NIS value at the bedside, and constructive feedback especially for patient care/safety and software functionality.

Use of a human factors approach to uncover informatics needs of nurses in documentation of care.

PURPOSE: The success of health information technology implementations is often tied to the impact the technical system will have on the work of the clinicians using them. Considering the role of nurses in healthcare, it is shocking that there is a lack of evaluations of nursing information systems in the literature. Here we report on how a human factors approach can be used to address barriers and facilitators to use of the nursing information system (NIS). Human factors engineering (HFE) approaches provide the theoretical and methodological underpinning to address these socio-technical issues. METHODS: This study investigated the use of an NIS, a module of the electronic health record (EHR) previously implemented throughout the hospital system. The study took place in two hospitals (760 beds and 300 beds) within a three-hospital health system. Earlier in the year, the NIS was implemented throughout the health system. We applied a scenario-based evaluation technique in order to understand the barriers and facilitators to nurse use of the NIS as part of improving the healthcare delivery system. The scenarios were designed to have the nurses interact with the major components of the NIS. The research team developed the standardized scenarios to cover the major functions of the system. RESULTS: Twelve nurses completed the study and results show that documentation within the NIS was hindered by several aspects of the interface. This paper discusses the themes associated with the usability of the NIS interface analyzing them using usability heuristics. The team also identified facilitators to use and proposed avenues to support or enhance these facilitators. CONCLUSIONS: This study examined the use of an NIS to standardize care and documentation in nursing. It used scenario-based usability testing, applying the "think-aloud" protocol technique to assess the use of the NIS in documenting patient care. This method of usability evaluation exposed an understanding of how nurses use the NIS and their perspective on the system. We hypothesize that this method will offer key insights into how the usability of the NIS not only impacts use but also informs redesign opportunities. In addition, this is one of the few rigorous studies of NIS and provides direction and recommendations for informaticians, developers and nurse decision makers.

Interdisciplinary care team adoption of electronic point-of-care documentation systems: an unrealized opportunity.

We conducted three health care evaluation studies in community and hospital settings to examine adoption of point-of-care documentation systems among interdisciplinary care team clinicians. Both community studies used a mixed methods design to assess actual system usage and clinician satisfaction. In the hospitals, scenario testing was used. Results indicated clinician adoption of the systems was universal, although not always timely with: (1) a mismatch between system functionality and workflow which was a barrier to clinician system access during patient care and reduced clinician efficiency; (2) no increase in interdisciplinary team communication; and (3) no impact on patient outcomes identified by clinicians. To facilitate adoption, clinicians should see the value of using the system as intended by receiving patient care and patient safety feedback that uses system data.

Community-based, interdisciplinary geriatric care team satisfaction with an electronic health record: a multimethod study.

This multimethod study measured the impact of an electronic health record (EHR) on clinician satisfaction with clinical process. Subjects were 39 clinicians at a Program of All-inclusive Care for Elders (PACE) site in Philadelphia utilizing an EHR. Methods included the evidence-based evaluation framework, Health Information Technology Research-Based Evaluation Framework, which guided assessment of clinician satisfaction with surveys, observations, follow-up interviews, and actual EHR use at two points in time. Mixed-methods analysis of findings provided context for interpretation and improved validity. The study found that clinicians were satisfied with the EHR; however, satisfaction declined between time periods. Use of EHR was universal and wide and was differentiated by clinical role. Between time periods, EHR use increased in volume, with increased timeliness and decreased efficiency. As the first EHR evaluation at a PACE site from the perspective of clinicians who use the system, this study provides insights into EHR use in the care of older people in community-based healthcare settings.