Buy or Build: Challenges Developing Consumer Digital Health Interventions.

BACKGROUND: Digital health interventions offer opportunities to improve collaborative care between clinicians and patients. Designing and implementing digital health interventions requires decisions about buying or building each technology-related component, all of which can lead to unanticipated issues. OBJECTIVES: This study aimed to describe issues encountered from our "buy or build" decisions developing two digital health interventions over different timeframes, designed to use patient-generated health data to: (1) improve hypertension control and (2) measure and improve adherence to HIV-related medications. METHODS: CONDUIT-HID (CONtrolling Disease Using Information Technology-Hypertension In Diabetes) was developed during 2010 to 2015 to allow patients receiving care from a multispecialty group practice to easily upload home blood pressure readings into their electronic health record and trigger clinician action if mean blood pressure values indicated inadequate control. USE-MI (Unobtrusive SEnsing of Medication Intake) was developed from 2016 to 2022 to allow entry of patients' HIV-related medication regimens, send reminders if patients had not taken their medications by the scheduled time(s), attempt to detect medication ingestion through machine learning analysis of smartwatch motion data, and present graphical adherence summaries to patients and clinicians. RESULTS: Both projects required multiple "buy or build" decisions across all system components, including data collection, transfer, analysis, and display. We used commercial, off-the-shelf technology where possible, but virtually all of these components still required substantial custom development. We found that, even though our projects spanned years, issues related to our "buy or build" decisions stemmed from several common themes, including mismatches between existing and new technologies, our use case being new or unanticipated, technology stability, technology longevity, and resource limitations. CONCLUSION: Those designing and implementing digital health interventions need to make numerous "buy or build" decisions as they create the technologies that underpin their intervention. These "buy or build" decisions, and the ensuing issues that will arise because of them, require careful planning, particularly if they represent an "edge case" use of existing commercial systems.

Designing a wrist-worn sensor to improve medication adherence: accommodating diverse user behaviors and technology preferences.

OBJECTIVES: High medication adherence is important for HIV suppression (antiretroviral therapy) and pre-exposure prophylaxis efficacy. We are developing sensor-based technologies to detect pill-taking gestures, trigger reminders, and generate adherence reports. MATERIALS AND METHODS: We collected interview, observation, and questionnaire data from individuals with and at-risk for HIV (N = 17). We assessed their medication-taking practices and physical actions, and feedback on our initial design. RESULTS: While participants displayed diverse medication taking practices and physical actions, most (67%) wanted to use the system to receive real-time and summative feedback, and most (69%) wanted to share data with their physicians. Participants preferred reminders via the wrist-worn device or mobile app, and summative feedback via mobile app or email. DISCUSSION: Adoption of these systems is promising if designs accommodate diverse behaviors and preferences. CONCLUSION: Our findings may help improve the accuracy and adoption of the system by accounting for user behaviors, physical actions, and preferences.

Predictors of Art and PrEP Adherence and Medication-Taking Practices and Preferences to Inform Development of a Wrist-Worn Adherence System.

We examined adherence, medication-taking practices, and preferences to inform development of a wrist-worn adherence system. Two convenience samples of persons taking antiretroviral therapy and HIV pre-exposure prophylaxis completed a survey. Additional online questions asked about willingness to use a wrist-worn device and reminder and feedback preferences. Among 225 participants, 13% reported adherence < 90%; this was associated with younger age and clinic sample. Compared to pill bottle-using participants, mediset users less commonly reported adherence < 90% (aOR = 0.16, p = .02), and blister pack users (aOR = 6.3, p = .02) and pill roll users (aOR = 3.3, p = .04) more commonly reported adherence < 90%. Sixty-two percent of the online participants reporting adherence (< 100%) had some interest in receiving adherence reminders, including 42% with interest in receiving reminders by smartwatch notifications. Although confounders are likely, formative work identified potential users and interest in using a wrist-worn adherence system. Future work will determine its acceptability and efficacy.

Keeping the patient in the center: Common challenges in the practice of shared decision making.

OBJECTIVE: To examine situations where shared decision making (SDM) in practice does not achieve the goal of a patient-centered decision. METHODS: We explore circumstances in which elements necessary to realize SDM - patient readiness to participate and understanding of the decision - are not present. We consider the influence of contextual factors on decision making. RESULTS: Patients' preference and readiness for participation in SDM are influenced by multiple interacting factors including the patient's comprehension of the decision, their emotional state, the strength of their relationship with the clinician, and the nature of the decision. Uncertainty often inherent in information can lead to misconceptions and ill-formed opinions that impair patients' understanding. In combination with cognitive biases, these factors may result in decisions that are incongruent with patients' preferences. The impact of suboptimal understanding on decision making may be augmented by the context. CONCLUSIONS: There are circumstances in which basic elements required for SDM are not present and therefore the clinician may not achieve the goal of a patient-centered decision. PRACTICE IMPLICATIONS: A flexible and tailored approach that draws on the full continuum of decision making models and communication strategies is required to achieve the goal of a patient-centered decision.

Does Maternal Buprenorphine Dose Affect Severity or Incidence of Neonatal Abstinence Syndrome?

OBJECTIVES: To measure the incidence, onset, duration, and severity of neonatal abstinence syndrome (NAS) in infants born to mothers receiving buprenorphine and to assess the association between buprenorphine dose and NAS outcomes. METHODS: We reviewed charts of all mother-infant pairs maintained on buprenorphine who delivered in our hospital from January 1, 2000 to April 1, 2016. RESULTS: In 89 infants, NAS incidence requiring morphine was 43.8%. Means for morphine-treated infants included: 55.2 hours to morphine start, 15.9 days on morphine, and 20 days hospital stay. NAS requiring morphine treatment occurred in 48.5% and 41.4% of infants of mothers receiving ≤8 mg/d buprenorphine versus >8 mg/d, respectively (P = 0.39). We found no significant associations of maternal buprenorphine dose with peak NAS score, NAS severity requiring morphine, time to morphine start, peak morphine dose, or days on morphine. Among the other factors examined, only exclusive breastfeeding was significantly associated with neonatal outcomes, specifically lower odds of morphine treatment (odds ratio 0.24, P = 0.003). CONCLUSIONS: These findings suggest higher buprenorphine doses can be prescribed to pregnant women receiving medication therapy for addiction without increasing NAS severity. Our finding of reduced risk of NAS requiring morphine treatment also suggests breastfeeding is both safe and beneficial for these infants and should be encouraged.

Can scribes boost FPs' efficiency and job satisfaction?

PURPOSE: Research in other medical specialties has shown that the addition of medical scribes to the clinical team enhances physicians' practice experience and increases productivity. To date, literature on the implementation of scribes in primary care is limited. To determine the feasibility and benefits of implementing scribes in family medicine, we undertook a pilot mixed- method quality improvement (QI) study. METHODS: In 2014, we incorporated 4 parttime scribes into an academic family medicine practice consisting of 7 physicians. We then measured, via survey and time-tracking data, the impact the scribes had on physician office hours and productivity, time spent on documentation, perceptions of work-life balance, and physician and patient satisfaction. RESULTS: Six of the 7 faculty physicians participated. This study demonstrated that the use of scribes in a busy academic primary care practice substantially reduced the amount of time that family physicians spent on charting, improved work-life balance, and had good patient acceptance. Specifically, the physicians spent an average of 5.1 fewer hours/week (hrs/wk) on documentation, while various measures of productivity revealed increases ranging from 9.2% to 28.8%. Perhaps most important of all, when the results of the pilot study were annualized, they were projected to generate $168,600 per year--more than twice the $79,500 annual cost of 2 full-time equivalent scribes. Surveys assessing work-life balance demonstrated improvement in the physicians' perception of the administrative burden/paperwork related to practice and a decrease in their perception of the extent to which work encroached on their personal lives. In addition, survey data from 313 patients at the time of their ambulatory visit with a scribe present revealed a high level of comfort. Likewise, surveys completed by physicians after 55 clinical sessions (ie, blocks of consecutive, uninterrupted patient appointments; there are usually 2 sessions per day) revealed good to excellent ratings more than 90% of the time. CONCLUSION: In an outpatient family medicine clinic, the use of scribes substantially improved physicians' efficiency, job satisfaction, and productivity without negatively impacting the patient experience.

Persuasive Interventions for Controversial Cancer Screening Recommendations: Testing a Novel Approach to Help Patients Make Evidence-Based Decisions.

PURPOSE: We wanted to evaluate novel decision aids designed to help patients trust and accept the controversial, evidence-based, US Preventive Services Task Force recommendations about prostate cancer screening (from 2012) and mammography screening for women aged 40 to 49 years (from 2009). METHODS: We created recorded vignettes of physician-patient discussions about prostate cancer screening and mammography, accompanied by illustrative slides, based on principles derived from preceding qualitative work and behavioral science literature. We conducted a randomized crossover study with repeated measures with 27 men aged 50 to 74 years and 35 women aged 40 to 49 years. All participants saw a video intervention and a more traditional, paper-based decision aid intervention in random order. At entry and after seeing each intervention, they were surveyed about screening intentions, perceptions of benefits and harm, and decisional conflict. RESULTS: Changes in screening intentions were analyzed without regard to order of intervention after an initial analyses showed no evidence of an order effect. At baseline, 69% of men and 86% of women reported wanting screening, with 31% and 6%, respectively, unsure. Mean change on a 3-point, yes, unsure, no scale was -0.93 (P = <.001) for men and -0.50 (P = <.001) for women after seeing the video interventions vs 0.0 and -0.06 (P = .75) after seeing the print interventions. At the study end, 33% of men and 49% of women wanted screening, and 11% and 20%, respectively, were unsure. CONCLUSIONS: Our novel, persuasive video interventions significantly changed the screening intentions of substantial proportions of viewers. Our approach needs further testing but may provide a model for helping patients to consider and accept evidence-based, counterintuitive recommendations.

Evaluation of online and in-person motivational interviewing training for healthcare providers.

INTRODUCTION: This study examines the outcomes of a 22-hr motivational interviewing (MI) course and compares online and in-person offerings of the course. It also evaluates clinicians' ability to accurately self-assess their MI skills. METHOD: 34 clinicians participated in this study and completed MI workshops either in-person or online. Use of MI in an acting patient encounter was recorded early in the training and again following the training. Recordings of these encounters were coded using the Motivational Interviewing Treatment Integrity (MITI) 3.1 coding system. After each acting patient encounter clinicians also self-evaluated their use of MI. RESULTS: Participants showed statistically significant improvement in MI skills measured by the MITI. There were no meaningful differences between the MI skills acquired by the participants in the online group compared with those who completed training in-person. There was little correlation between participants' self-assessment of MI skills and objective assessment. DISCUSSION: It is feasible to complete MI training through synchronous online workshops. Participant self-assessment of MI skill does not appear to be a useful approach for assessing MI skill. The acquisition of MI skills by health professionals is possible via the Internet. Learning should be assessed using objective measures rather than relying on self-report. (PsycINFO Database Record

A Qualitative Study of Vulnerable Patient Views of Type 2 Diabetes Consumer Reports.

BACKGROUND: The Patient Protection and Affordable Care Act (ACA) mandates the release of publicly available consumer reports to highlight differences in quality of care and reduce healthcare disparities. However, little is known about patient perceptions of the value of such reports. OBJECTIVE: This study aims to identify whether vulnerable populations with type 2 diabetes perceive consumer reports as helpful in making decisions about diabetes care. METHODS: We conducted a brief demographic survey and qualitative study of 18 focus groups: six each of African American, Hispanic, and non-Hispanic White consumers diagnosed with type 2 diabetes (n = 92). We analysed focus group transcripts to identify recurring themes, which were summarized and compared across population groups. RESULTS: Participants expressed minimal interest in currently available consumer reports. They instead listed personal referrals and interpersonal interactions among the most important factors when choosing a physician. Further, in place of information to aid in physician selection, participants articulated strong desires for more basic, straightforward disease-specific information that would promote diabetes self-management. CONCLUSIONS: This study's results call into question the value of consumer reports as defined by the ACA. Participants reported little interest in comparative provider performance data. Instead, they were more interested in information to assist in diabetes self-management. This suggests that consumer reports may not be as important a tool to improve outcomes and reduce health disparities as policy makers imagine them to be.

Challenges in developing primary care physicians' motivational interviewing skills.

INTRODUCTION: Motivational interviewing (MI) skills are relevant for primary care providers (PCPs) who are responsible for caring for patients with diseases affected by behavior. There are significant challenges associated with developing PCP's MI skills. We report on an effort to document the acquisition of MI skills by PCPs using an objective measure of MI competence, the Motivational Interviewing Treatment Integrity (MITI) coding system. METHOD: Eleven PCPs volunteered to participate in 6 MI workshops over a period of 6 months and to submit work samples between each of these workshops to be assessed with the MITI coding system. RESULTS: Thirteen of the expected 55 work samples were submitted before the final workshop. A revised approach was implemented in which each participant completed 2 simulated patient encounters. None of the providers reached the MITI's Beginning Proficiency threshold of MI skill. DISCUSSION: Six MI workshops were not sufficient to help motivated PCPs achieve Beginning Proficiency as measured by the MITI. Participants failed to submit most of the work samples for feedback on their MI practice, which may have contributed to their limited acquisition of MI skills. Helping PCPs develop MI skills likely requires more than participation in a series of workshops totaling 18 h. Questions remain about the feasibility of training PCPs to be competent in MI. Approaches such as use of simulated patients, peer observation, or specific protected time for obtaining work samples may be required. (PsycINFO Database Record

Inaccurate risk perceptions and individualized risk estimates by patients with type 2 diabetes.

BACKGROUND: We evaluated how diabetic patients understand and respond to the presentation of personalized risk information. METHODS: This was a mixed methods study involving 56 patients with type 2 diabetes and at least 1 additional cardiovascular risk factor. We assessed participants' perceptions of diabetes-related risks; asked them to rank order 6 events (death, heart attack, stroke, blindness, amputation, and kidney failure) by likelihood of occurrence in a specified time frame; presented them with personalized risk estimates; and asked them to re-rank the risks. The final 18 participants were tested to verify understanding before re-ranking risks. Qualitative analysis of interview transcripts identified themes and concepts underlying participants' ways of perceiving and reacting to risk. RESULTS: While mortality was the most likely outcome for almost all participants, nearly all estimated it to be least likely; only 28% adjusted their mortality rankings to match model predictions. Some did not understand the risk information: only two thirds of those asked could rank risks according to the information presented. Risk perceptions were influenced by factors including "knowing myself," powerful anecdotes, and belief that a "warning shot" would occur before death. CONCLUSIONS: Personalized risk estimates, particularly about mortality, had limited salience. Some participants could not understand the information, despite presentation in ways suggested by previous research.

The central role of comorbidity in predicting ambulatory care sensitive hospitalizations.

BACKGROUND: Ambulatory care sensitive hospitalizations (ACSHs) are commonly used as measures of access to and quality of care. They are defined as hospitalizations for certain acute and chronic conditions; yet, they are most commonly used in analyses comparing different groups without adjustment for individual-level comorbidity. We present an exploration of their roles in predicting ACSHs for acute and chronic conditions. METHODS: Using 1998-99 US Medicare claims for 1 06 930 SEER-Medicare control subjects and 1999 Area Resource File data, we modelled occurrence of acute and chronic ACSHs with logistic regression, examining effects of different predictors on model discriminatory power. RESULTS: Flags for the presence of a few comorbid conditions-congestive heart failure, chronic obstructive pulmonary disease, diabetes, hypertension and, for acute ACSHs, dementia-contributed virtually all of the discriminative ability for predicting ACSHs. C-statistics were up to 0.96 for models predicting chronic ACSHs and up to 0.87 for predicting acute ACSHs. C-statistics for models lacking comorbidity flags were lower, at best 0.73, for both acute and chronic ACSHs. CONCLUSION: Comorbidity is far more important in predicting ACSH risk than any other factor, both for acute and chronic ACSHs. Imputations about quality and access should not be made from analyses that do not control for presence of important comorbid conditions. Acute and chronic ACSHs differ enough that they should be modelled separately. Unaggregated models restricted to persons with the relevant diagnoses are most appropriate for chronic ACSHs.

Overcoming challenges integrating patient-generated data into the clinical EHR: lessons from the CONtrolling Disease Using Inexpensive IT--Hypertension in Diabetes (CONDUIT-HID) Project.

INTRODUCTION: The CONDUIT-HID intervention integrates patients' electronic blood pressure measurements directly into the clinical EHR using Microsoft HealthVault as an intermediary data store. The goal of this paper is to describe generalizable categories of patient and technical challenges encountered in the development and implementation of this inexpensive, commercial off-the-shelf consumer health informatics intervention, examples of challenges within each category, and how the example challenges were resolved prior to conducting an RCT of the intervention. METHODS: The research team logged all challenges and mediation strategies during the technical development of the intervention, conducted home visits to observe patients using the intervention, and conducted telephone calls with patients to understand challenges they encountered. We then used these data to iteratively refine the intervention. RESULTS: The research team identified a variety of generalizable categories of challenges associated with patients uploading data from their homes, patients uploading data from clinics because they did not have or were not comfortable using home computers, and patients establishing the connection between HealthVault and the clinical EHR. Specific challenges within these categories arose because: (1) the research team had little control over the device and application design, (2) multiple vendors needed to coordinate their actions and design changes, (3) the intervention use cases were not anticipated by the device and application designers, (4) PHI accessed on clinic computers needed to be kept secure, (5) the research team wanted the data in the clinical EHR to be valid and reliable, (6) patients needed the ability to share only the data they wanted, and (7) the development of some EHR functionalities were new to the organization. While these challenges were varied and complex, the research team was able to successfully resolve each one prior to the start of the RCT. CONCLUSIONS: By identifying these generalizable categories of challenges, we aim to help others proactively search for and remedy potential challenges associated with their interventions, rather than reactively responding to problems as they arise. We posit that this approach will significantly increase the likelihood that these types of interventions will be successful.

Provision of contraceptive services to homeless women: results of a survey of health care for the homeless providers.

Homeless women have both a higher rate of pregnancy and a higher proportion of unintended pregnancies than other American women. The authors sought to learn about contraception services offered by providers of health care to homeless women and barriers to provision of long-acting, reversible contraception in these settings. A survey of the 31 member organizations in the national Health Care for the Homeless Practice-Based Research Network was conducted, inquiring about services provided and barriers to service provision. Among the 20 responding organizations (65% response rate), 17 directly provided contraceptive services; two referred patients elsewhere, and one provided no contraceptive services. All 17 that provided such services provided condoms; 15 provided oral contraceptives; 14 provided injectable contraception; 6 provided intrauterine devices, and 2 provided contraceptive implants. Barriers to providing the last two methods included lack of provider training, lack of resources for placement, costs, and concerns about complications. The present survey results suggested very limited access for homeless women across the country to the two most effective means of long-acting, reversible contraception. Modest investments of resources could reduce a number of barriers to providing these services.