Colonoscopy Outreach for Rural Communities (CORC): A study protocol of a pragmatic randomized controlled trial of a patient navigation program to improve colonoscopy completion for colorectal cancer screening.

BACKGROUND: Colonoscopy is one of the primary methods of screening for colorectal cancer (CRC), a leading cause of cancer mortality in the United States. However, up to half of patients referred to colonoscopy fail to complete the procedure, and rates of adherence are lower in rural areas. OBJECTIVES: Colonoscopy Outreach for Rural Communities (CORC) is a randomized controlled trial to test the effectiveness of a centralized patient navigation program provided remotely by a community-based organization to six geographically distant primary care organizations serving rural patients, to improve colonoscopy completion for CRC. METHODS: CORC is a type 1 hybrid implementation-effectiveness trial. Participants aged 45-76 from six primary care organizations serving rural populations in the northwestern United States are randomized 1:1 to patient navigation or standard of care control. The patient navigation is delivered remotely by a trained lay-person from a community-based organization. The primary effectiveness outcome is completion of colonoscopy within one year of referral to colonoscopy. Secondary outcomes are colonoscopy completion within 6 and 9 months, time to completion, adequacy of patient bowel preparation, and achievement of cecal intubation. Analyses will be stratified by primary care organization. DISCUSSION: Trial results will add to our understanding about the effectiveness of patient navigation programs to improve colonoscopy for CRC in rural communities. The protocol includes pragmatic adaptations to meet the needs of rural communities and findings may inform approaches for future studies and programs. TRIAL REGISTRATION: National Clinical Trial Identifier: NCT05453630. TRIAL REGISTRATION: ClinicalTrials.gov. Identifier: NCT05453630. Registered July 6, 2022.

Identifying patients with opioid use disorder using International Classification of Diseases (ICD) codes: Challenges and opportunities.

BACKGROUND AND AIMS: International Classification of Diseases (ICD) diagnosis codes are often used in research to identify patients with opioid use disorder (OUD), but their accuracy for this purpose is not fully evaluated. This study describes application of ICD-10 diagnosis codes for opioid use, dependence and abuse from an electronic health record (EHR) data extraction using data from the clinics' OUD patient registries and clinician/staff EHR entries. DESIGN: Cross-sectional observational study. SETTING: Four rural primary care clinics in Washington and Idaho, USA. PARTICIPANTS: 307 patients. MEASUREMENTS: This study used three data sources from each clinic: (1) a limited dataset extracted from the EHR, (2) a clinic-based registry of patients with OUD and (3) the clinician/staff interface of the EHR (e.g. progress notes, problem list). Data source one included records with six commonly applied ICD-10 codes for opioid use, dependence and abuse: F11.10 (opioid abuse, uncomplicated), F11.20 (opioid dependence, uncomplicated), F11.21 (opioid dependence, in remission), F11.23 (opioid dependence with withdrawal), F11.90 (opioid use, unspecified, uncomplicated) and F11.99 (opioid use, unspecified with unspecified opioid-induced disorder). Care coordinators used data sources two and three to categorize each patient identified in data source one: (1) confirmed OUD diagnosis, (2) may have OUD but no confirmed OUD diagnosis, (3) chronic pain with no evidence of OUD and (4) no evidence for OUD or chronic pain. FINDINGS: F11.10, F11.21 and F11.99 were applied most frequently to patients who had clinical diagnoses of OUD (64%, 89% and 79%, respectively). F11.20, F11.23 and F11.90 were applied to patients who had a diagnostic mix of OUD and chronic pain without OUD. The four clinics applied codes inconsistently. CONCLUSIONS: Lack of uniform application of ICD diagnosis codes make it challenging to use diagnosis code data from EHR to identify a research population of persons with opioid use disorder.

Stakeholder perspectives on a telemedicine referral and coordination model to expand medication treatment for opioid use disorder in rural primary care clinics.

INTRODUCTION: Opioid overdose deaths are increasing rapidly in the United States. Medications for opioid use disorder (MOUD) are effective and can be delivered in primary care, but uptake has been limited in rural communities. Referral to and coordination with an external telemedicine (TM) vendor by rural primary care clinics for MOUD (TM-MOUD) may increase MOUD access for rural patients, but we know little about perspectives on this model among key stakeholders. As part of a TM-MOUD feasibility study, we explored TM-MOUD acceptability and feasibility among personnel and patients from seven rural primary care clinics and a TM-MOUD vendor. METHODS: We conducted virtual interviews or focus groups with clinic administrators (n = 7 interviews), clinic primary care and behavioral health providers (8 groups, n = 30), other clinic staff (9 groups, n = 37), patients receiving MOUD (n = 16 interviews), TM-MOUD vendor staff (n = 4 interviews), and vendor-affiliated behavioral health and prescribing providers (n = 17 interviews). We asked about experiences with and acceptability of MOUD (primarily buprenorphine) and telemedicine (TM) and a TM-MOUD referral and coordination model. We conducted content analysis to identify themes and participants quantitatively rated acceptability of TM-MOUD elements on a 4-item scale. RESULTS: Perceived benefits of vendor-based TM-MOUD included reduced logistical barriers, more privacy and less stigma, and access to services not available locally (e.g., counseling, pain management). Barriers included lack of internet or poor connectivity in patients' homes, limited communication and trust between TM-MOUD and clinic providers, and questions about the value to the clinic of TM-MOUD referral to external vendor. Acceptability ratings for TM-MOUD were generally high; they were lowest among frontline staff. CONCLUSIONS: Rural primary care clinic personnel, TM-MOUD vendor personnel, and patients generally perceived referral from primary care to a TM-MOUD vendor to hold potential for increasing access to MOUD in rural communities. Increasing TM-MOUD uptake requires buy-in and understanding among staff of the TM-MOUD workflow, TM services offered, requirements for patients, advantages over clinic-based or TM services from clinic providers, and identification of appropriate patients. Poverty, along with patient hesitation to initiate treatment, creates substantial barriers to MOUD treatment generally; insufficient internet availability creates a substantial barrier to TM-MOUD.

Care coordination between rural primary care and telemedicine to expand medication treatment for opioid use disorder: Results from a single-arm, multisite feasibility study.

PURPOSE: The use of telemedicine (TM) has accelerated in recent years, yet research on the implementation and effectiveness of TM-delivered medication treatment for opioid use disorder (MOUD) has been limited. This study investigated the feasibility of implementing a care coordination model involving MOUD delivered via an external TM provider for the purpose of expanding access to MOUD for patients in rural settings. METHODS: The study tested a care coordination model in 6 rural primary care sites by establishing referral and coordination between the clinic and a TM company for MOUD. The intervention spanned approximately 6 months from July/August 2020 to January 2021, coinciding with the peak of the COVID-19 pandemic. Each clinic tracked patients with OUD in a registry during the intervention period. A pre-/post-intervention design (N = 6) was used to assess the clinic-level outcome as patient-days on MOUD based on patient electronic health records. FINDINGS: All clinics implemented critical components of the intervention, with an overall TM referral rate of 11.7% among patients in the registry. Five of the 6 sites showed an increase in patient-days on MOUD during the intervention period compared to the 6-month period before the intervention (mean increase per 1,000 patients: 132 days, P = .08, Cohen's d = 0.55). The largest increases occurred in clinics that lacked MOUD capacity or had a greater number of patients initiating MOUD during the intervention period. CONCLUSIONS: To expand access to MOUD in rural settings, the care coordination model is most effective when implemented in clinics that have negligible or limited MOUD capacity.

Usability Issues in Evidence-Based Psychosocial Interventions and Implementation Strategies: Cross-project Analysis.

BACKGROUND: People often prefer evidence-based psychosocial interventions (EBPIs) for mental health care; however, these interventions frequently remain unavailable to people in nonspecialty or integrated settings, such as primary care and schools. Previous research has suggested that usability, a concept from human-centered design, could support an understanding of the barriers to and facilitators of the successful adoption of EBPIs and support the redesign of EBPIs and implementation strategies. OBJECTIVE: This study aimed to identify and categorize usability issues in EBPIs and their implementation strategies. METHODS: We adapted a usability issue analysis and reporting format from a human-centered design. A total of 13 projects supported by the National Institute of Mental Health-funded Accelerating the Reach and Impact of Treatments for Youth and Adults with Mental Illness Center at the University of Washington used this format to describe usability issues for EBPIs and implementation strategies with which they were working. Center researchers used iterative affinity diagramming and coding processes to identify usability issue categories. On the basis of these categories and the underlying issues, we propose heuristics for the design or redesign of EBPIs and implementation strategies. RESULTS: The 13 projects reported a total of 90 usability issues, which we categorized into 12 categories, including complex and/or cognitively overwhelming, required time exceeding available time, incompatibility with interventionist preference or practice, incompatibility with existing workflow, insufficient customization to clients/recipients, intervention buy-in (value), interventionist buy-in (trust), overreliance on technology, requires unavailable infrastructure, inadequate scaffolding for client/recipient, inadequate training and scaffolding for interventionists, and lack of support for necessary communication. These issues range from minor inconveniences that affect a few interventionists or recipients to severe issues that prevent all interventionists or recipients in a setting from completing part or all of the intervention. We propose 12 corresponding heuristics to guide EBPIs and implementation strategy designers in preventing and addressing these usability issues. CONCLUSIONS: Usability issues were prevalent in the studied EBPIs and implementation strategies. We recommend using the lens of usability evaluation to understand and address barriers to the effective use and reach of EBPIs and implementation strategies. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/14990.

Is telemedicine the answer to rural expansion of medication treatment for opioid use disorder? Early experiences in the feasibility study phase of a National Drug Abuse Treatment Clinical Trials Network Trial.

Telemedicine (TM) enabled by digital health technologies to provide medical services has been considered a key solution to increasing health care access in rural communities. With the immediate need for remote care due to the COVID-19 pandemic, many health care systems have rapidly incorporated digital technologies to support the delivery of remote care options, including medication treatment for individuals with opioid use disorder (OUD). In responding to the opioid crisis and the COVID-19 pandemic, public health officials and scientific communities strongly support and advocate for greater use of TM-based medication treatment for opioid use disorder (MOUD) to improve access to care and have suggested that broad use of TM during the pandemic should be sustained. Nevertheless, research on the implementation and effectiveness of TM-based MOUD has been limited. To address this knowledge gap, the National Drug Abuse Treatment Clinical Trials Network (CTN) funded (via the NIH HEAL Initiative) a study on Rural Expansion of Medication Treatment for Opioid Use Disorder (Rural MOUD; CTN-0102) to investigate the implementation and effectiveness of adding TM-based MOUD to rural primary care for expanding access to MOUD. In preparation for this large-scale, randomized controlled trial incorporating TM in rural primary care, a feasibility study is being conducted to develop and pilot test implementation procedures. In this commentary, we share some of our experiences, which include several challenges, during the initial two-month period of the feasibility study phase. While these challenges could be due, at least in part, to adjusting to the COVID-19 pandemic and new workflows to accommodate the study, they are notable and could have a substantial impact on the larger, planned pragmatic trial and on TM-based MOUD more broadly. Challenges include low rates of identification of risk for OUD from screening, low rates of referral to TM, digital device and internet access issues, workflow and capacity barriers, and insurance coverage. These challenges also highlight the lack of empirical guidance for best TM practice and quality remote care models. With TM expanding rapidly, understanding implementation and demonstrating what TM approaches are effective are critical for ensuring the best care for persons with OUD.

Assessing the Usability of Complex Psychosocial Interventions: The Intervention Usability Scale.

Background: Usability - the extent to which an intervention can be used by specified users to achieve specified goals with effectiveness, efficiency, and satisfaction - may be a key determinant of implementation success. However, few instruments have been developed to measure the design quality of complex health interventions (i.e., those with several interacting components). This study evaluated the structural validity of the Intervention Usability Scale (IUS), an adapted version of the well-established System Usability Scale (SUS) for digital technologies, to measure the usability of a leading complex psychosocial intervention, Motivational Interviewing (MI), for behavioral health service delivery in primary care. Prior SUS studies have found both one- and two-factor solutions, both of which were examined in the current study of the IUS. Method: A survey administered to 136 medical professionals from 11 primary care sites collected demographic information and IUS ratings for MI, the evidence-based psychosocial intervention that primary care providers reported using most often for behavioral health service delivery. Factor analyses replicated procedures used in prior research on the SUS. Results: Analyses indicated that a two-factor solution (with "usable" and "learnable" subscales) best fit the data, accounting for 54.1% of the variance. Inter-item reliabilities for the total score, usable subscale, and learnable subscale were α = .83, α = .84, and α = .67, respectively. Conclusions: This study provides evidence for a two-factor IUS structure consistent with some prior research, as well as acceptable reliability. Implications for implementation research evaluating the usability of complex health interventions are discussed, including the potential for future comparisons across multiple interventions and provider types, as well as the use of the IUS to evaluate the relationship between usability and implementation outcomes such as feasibility.

Personal health information management among healthy older adults: Varying needs and approaches.

OBJECTIVE: With age, older adults experience a greater number of chronic diseases and medical visits, and an increased need to manage their health information. Technological advances in consumer health information technologies (HITs) help patients gather, track, and organize their health information within and outside of clinical settings. However, HITs have not focused on the needs of older adults and their caregivers. The goal of the SOARING (Studying Older Adults and Researching their Information Needs and Goals) Project was to understand older adult personal health information management (PHIM) needs and practices to inform the design of HITs that support older adults. MATERIALS AND METHODS: Drawing on the Work System Model, we took an ecological approach to investigate PHIM needs and practices of older adults in different residential settings. We conducted in-depth interviews and surveys with adults 60 years of age and older. RESULTS: We performed on-site in-person interview sessions with 88 generally healthy older adults in various settings including independent housing, retirement communities, assisted living, and homelessness. Our analysis revealed 5 key PHIM activities that older adults engage in: seeking, tracking, organizing, sharing health information, and emergency planning. We identified 3 major themes influencing older adults' practice of PHIM: (1) older adults are most concerned with maintaining health and preventing illness, (2) older adults frequently involve others in PHIM activities, and (3) older adults' approach to PHIM is situational and context-dependent. DISCUSSION: Older adults' approaches to PHIM are dynamic and sensitive to changes in health, social networks, personal habits, motivations, and goals. CONCLUSIONS: PHIM tools that meet the needs of older adults should accommodate the dynamic nature of aging and variations in individual, organizational, and social contexts.

Older Adult Health-Related Support Networks: Implications for the Design of Digital Communication Tools.

BACKGROUND AND OBJECTIVES: Digital communication tools facilitate the provision of health-related social support to older adults. However, little is known about what design features make such tools most useful and feasible. The purpose of this study was to describe health-related social support networks of older adults and outline recommendations for the design of tools that facilitate the giving and receiving of support. RESEARCH DESIGN AND METHODS: We collected data through validated instruments and semistructured qualitative interviews with 88 older adults. We calculated descriptive statistics for the quantitative data and analyzed qualitative data using directed content analysis. RESULTS: Health-related support networks described by our sample of generally healthy older adults varied in size from 0 to 10 members. Some networks did not include any family members, and others did not include any friends. Seventy-four percent of network members lived in the same state as the older adult participant, but only 15% of them lived with the participant. Emotional support was the main type of health-related support provided, followed by instrumental, informational, and appraisal support. DISCUSSION AND IMPLICATIONS: Health-related support networks of older adults are varied and complex. Our results suggest that digital communication tools to promote and leverage support from network members should facilitate the involvement of friends and family regardless of their physical location, allow for the transparent allocation of concrete tasks to prevent overburdening any one network member, and facilitate sharing of personal health information with family and friends while ensuring privacy and autonomy.

Home Care Nurses' Perspectives Regarding Health Information Management Among Older Adults.

Aging is associated with comorbidities and increased utilization of healthcare services, which results in a large amount of personal health information (PHI) to manage. Older adults often have difficulty managing this increased load of health information. Although many home healthcare nurses (HCNs) provide assistance to older adults after discharge from medical facilities, little is known about HCNs' experiences with older adults regarding the management and transfer of PHI in their homes. The purpose of this qualitative study was to 1) determine how HCNs obtain and provide health information, 2) describe the perspective of HCNs regarding older adult PHI, and 3) identify the potential role of technology in older adult health information transfer. We conducted and analyzed semistructured phone interviews with 17 HCNs from two home healthcare agencies. Five thematic areas emerged from interviews with HCNs: 1) common practices of obtaining health information; 2) barriers to obtaining health information; 3) ideal ways to obtain and provide health information; 4) use of patient portals; and 5) HCNs' use of technology for health information exchange. Most HCNs reported that it would be difficult for older adult patients to update their PHI without assistance, but HCNs lack the time and resources to assist older adults in PHI management activities.

Personal Health Information Management Practices of Older Adults: One Size Does Not Fit All.

Older adults are the largest consumers of health care, have the greatest number of chronic conditions, and generate the greatest amount of health data. Yet, information systems designed to aid health information management do not align with their needs and practices. We describe a process of identifying the personal health information management (PHIM) activities and objectives of older adults (60 years and older) from different residential settings.

Examining the Needs of Patient Stakeholders as Research Partners in Health Data Networks for Translational Research.

Patient stakeholders are getting increasingly involved in research health data networks, particularly as research partners. However, tools do not exist to help effectively orient, educate, and engage patient stakeholders as they take on these roles. Using a human centered design approach, we conducted a patient stakeholder needs assessment qualitative study to identify key user needs to drive design recommendations for development of an online education and engagement tool for research health data networks. We found three key needs related to multiple role identities, motivations and expectations for participation on research teams, and patient journeys. Design recommendations derived from the needs assessment are discussed that can support future tool design and testing.

Monitoring for change: the role of family and friends in helping older adults manage personal health information.

Objective: Although family and friends (FF) often play a significant support role in the health of older adults (OA), we know little about their role in personal health information management (PHIM). To address this gap and inform the design of PHIM tools, we describe the work, needs, and barriers of FF in the context of PHIM for OAs. Methods: We conducted semi-structured telephone interviews with 52 FF identified by OA as being important in their health and PHIM. We analyzed interview transcripts for themes about FF information work, barriers, and support needs. Results: FF play a supportive role in OA health maintenance, medical encounters, decision making, and daily activities. Monitoring, the ongoing process of seeking information related to the OA status, emerged as a key activity comprised of 3 phases: detection, interpretation, and action. Barriers to monitoring included OA choices and constraints, FF constraints, and difficulty with technological tools, resources, health information exchange between providers, social network dynamics, and physical distance. Conclusions: FF frequently monitor for change in OA well-being, seeking up-to-date information to facilitate support of OA PHIM. Health information technology tools designed for FF can support all phases of monitoring by providing: (1) timely and granular levels of access to OA health information as the OA ages; (2) tailored health education for FF that is based on OA clinical data; and (3) networking platforms that integrate delegation, volunteering, and relevant resources, along with tools to facilitate support of OA appointment calendars and medication management. Such tools could reduce the burden of PHIM for OA and their loved ones.

Emergency information management needs and practices of older adults: A descriptive study.

OBJECTIVE: To better understand how older adults currently manage emergency information, the barriers and facilitators to planning and management of emergency information, as well as the potential role of information technology to facilitate emergency planning and management. INTRODUCTION: Older adults face a much higher risk of sudden illness/injury and are the age group with the largest percentages of emergent and urgent healthcare visits. Emergency information (health information needed in an emergency situation such as emergency contact information, diagnoses, and advance directives) needs to be maintained and easily accessible to ensure older adults get appropriate care and treatment consistent with their wishes in emergency situations. Current health information technologies rarely take into consideration the emergency information needs of older adults, their caregivers, and emergency responders. METHODS: As part of a larger study we performed in-depth interviews with 90 older adults living in a variety of residential settings (independent living, retirement communities, assisted living) regarding how they manage information about their health. Interview sessions included photos of important health information artifacts. Interviews were transcribed and coded. RESULTS: Analysis of in-depth interviews revealed that emergency information is a type of health information that older adults frequently manage. Participants differed in whether they practice emergency planning (e.g. the preparation and continued management of emergency information), and in whether they involve others in emergency information and emergency planning. Despite its importance, emergency information was often not up-to-date and not always kept in locations readily apparent to emergency responders. CONCLUSION: Emergency information, such as emergency contact information, diagnoses, and advance directives, is a type of health information that older adults manage. Considering emergency information in the design of health information technologies for older adults could address some of the barriers and support the facilitators to emergency planning and information management.

A Closer Look at Health Information Seeking by Older Adults and Involved Family and Friends: Design Considerations for Health Information Technologies.

Older adults are the largest consumers of healthcare. As part of a broader study of personal health information management (PHIM), we interviewed older adults in King County, Washington, and their involved family and friends (FF), regarding health information (HI) sources they seek and utilize. Analysis of interview transcripts revealed four main themes: 1) older adults and FF consider healthcare providers the foundational source of HI; 2) older adults utilize FF for seeking, sharing, and interpreting HI, while FF serve as surrogate seekers and experience-based experts; 3) online searching is common for older adults and FF, but confidence in assessing the quality of online HI is often lacking; 4) a smorgasbord approach is frequently utilized by older adults and FF for gathering and clarifying HI. Design considerations include: facilitating access to quality provider-vetted HI, incorporating older adults and FF in the design process, and creating shared spaces for communication of HI among older adults, FF, and providers.

Use of Patient Portals: Personal Health Information Management in Older Adults.

The personal health information management (PHIM) of older adults is poorly understood. We describe initial results from the SOARING (Studying Older Adults & Researching Information Needs and Goals) study at the University of Washington, a participatory design investigation of PHIM in older adults. We conducted in-depth interviews with older adults (n=71) living in a variety of residential settings. A surprising 21% of participants reported using patient portals. Another 17% of participants reported prior use or anticipated use of portals in the future. We identified preferences and needs as well as barriers and facilitators to portal use. Our findings indicate that patient portals designed to target the specific needs for older adults can suport PHIM. We offer recommendations for expanded research.

Use of Patient Portals for Personal Health Information Management: The Older Adult Perspective.

The personal health information management (PHIM) practices and needs of older adults are poorly understood. We describe initial results from the UW SOARING project (Studying Older Adults & Researching Information Needs and Goals), a participatory design investigation of PHIM in older adults (60 years and older). We conducted in-depth interviews with older adults (n=74) living in a variety of residential settings about their management of personal health information. A surprising 20% of participants report using patient portals and another 16% reported prior use or anticipated use of portals in the future. Participants cite ease of access to health information and direct communication with providers as valuable portal features. Barriers to the use of patient portals include a general lack of computer proficiency, high internet costs and security concerns. Design features based on consideration of needs and practices of older adults will facilitate appeal and maximize usability; both are elements critical to adoption of tools such as patient portals that can support older adults and PHIM.