BMT Roadmap: A User-Centered Design Health Information Technology Tool to Promote Patient-Centered Care in Pediatric Hematopoietic Cell Transplantation

Child and Family Outcomes and Experiences Related to Family-Centered Care Interventions for Hospitalized Pediatric Patients: A Systematic Review

BACKGROUND/OBJECTIVES

Family-centered care (FCC) is the recommended model for pediatric inpatient care. Our overall aim was to conduct a narrative synthesis of the contemporary published research on the effectiveness of FCC interventions for pediatric inpatients. Our specific objective was to critique studies of inpatient pediatric FCC interventions that evaluated child or parent outcomes.

METHODS

We searched five databases (Pubmed, CINAHL, Embase, PsychInfo, and Web of Science) for peer-reviewed research published from 1 January 2017 to 6 February 2024. Independent reviewers evaluated each study based on pre-specified inclusion and exclusion criteria, then extracted and narratively synthesized the data.

RESULTS

We found 16 studies of 15 interventions conducted in six countries. The studies were quantitative (n = 11), qualitative (n = 3), and mixed methods (n = 2), with most designs being of low to moderate quality based on a modified Mixed-Methods Appraisal Tool. Interventions included family-centered rounds, parent-focused health information technology, education, patient navigation, parent-peer support, partnership, and parent participation in caregiving. Most studies found significant improvements in parents' well-being, knowledge, and participation, as well as decreased stress and anxiety with the FCC interventions compared to usual care. One study found no differences in child outcomes (infant feeding, length of stay) between usual care and a parent-participation intervention.

CONCLUSIONS

Although FCC interventions led to many improved outcomes for parents, there were few well-designed comparison studies using validated tools and well-defined interventions. Higher quality research is needed to promote greater uptake and sustainability of FCC interventions globally.

Support interventions offered to family members of a child treated with hematopoietic stem cell transplant: A scoping review

A scoping review was conducted to explore support interventions for family members of a child treated with hematopoietic stem cell transplant (HSCT). Three databases (CINAHL, Embase, and Medline) were searched to answer the review question: What are the support interventions offered to family members of a child treated with HSCT and are they based on a family-centred care approach? Out of 665 screened articles, nine were selected for full review. Findings revealed two main types of family-centred support interventions: psychological face-to-face and technology-based interventions. The majority of interventions assisted in improving family members' psychological well-being and included a portion of the core concepts from the Institute for Patient and Family-Centered Care Model in their approach. Based on the review findings, interventions that incorporate family-centred care concepts can enhance the psychological well-being and quality of life of family members whose child is undergoing HSCT treatment.

Revue exploratoire des interventions de soutien offertes aux membres de la famille d’un enfant subissant une greffe de cellules souches hématopoïétiques

Nous avons effectué cette revue exploratoire pour connaître les interventions de soutien offertes actuellement aux membres de la famille d’un enfant subissant une greffe de cellules souches hématopoïétiques (GCSH). Nous avons consulté trois bases de données (CINAHL, Embase et Medline) pour répondre à la question suivante : Quelles sont les interventions de soutien offertes aux membres de la famille d’un enfant subissant une greffe de cellules souches hématopoïétiques, et sont-elles fondées sur une approche de soins axés sur la famille? Parmi les 665 articles présélectionnés, nous en avons retenu neuf à lire au complet. Nos résultats montrent qu’il existe deux principaux types d’interventions de soutien axées sur la famille : les interventions psychologiques en personne et les interventions pratiquées à l’aide de la technologie. La plupart de ces interventions ont contribué à améliorer le bien-être psychologique des membres de la famille et s’appuyaient sur certains principes du modèle de soins de l’Institute for Patient- and Family-Centered Care. La présente revue exploratoire nous permet d’affirmer que les interventions qui s’appuient sur les principes des soins axés sur la famille peuvent améliorer le bien-être psychologique et la qualité de vie des membres de la famille d’un enfant subissant une GCSH.

Standardization of Pediatric Hematopoietic Stem Cell Transplant Patient Discharge to Reduce Readmission Rates

Background: The time period after a pediatric hematopoietic stem cell transplant (P-HSCT) is tenuous as the patient is severely immunocompromised and awaiting immune reconstitution. Managing activities of daily living and medication administration after discharge from the hospital requires 24-hour care placing a heavy burden on caregivers and patients. Patients who do not adhere to the posttransplant regimen are at a higher risk for hospital readmission within the first 30 days of initial discharge with serious potential for life-threatening complications. The objective of this project was to improve 30-day readmission rates and caregiver readiness for discharge through the implementation of an evidence-based discharge protocol for P-HSCT patients and caregivers. Methods: This quality improvement project included development and implementation of comprehensive Pediatric Blood & Marrow Transplant Guidelines and discharge protocol for patients who received an inpatient autologous or allogeneic HSCT and were scheduled for discharge from a 16-bed inpatient pediatric hematology-oncology unit of a children's hospital in the southeastern United States. Readmission rates were captured through the hospital-monitored system. Results: The comprehensive discharge protocol was implemented for six patients, and 30-day readmission rates decreased from 27.29% to 3.57% following the intervention. Discussion: Results suggest the combination of an evidence-based discharge protocol with a focus on caregiver readiness for discharge and a 24-hour Rooming-In period can influence caregiver confidence and reduce 30-day readmission rates after initial discharge from a P-HSCT.

Feasibility & Acceptability of Patient and Family Directed Active Music Making during Pediatric Bone Marrow Transplant Process

(1) Background: Bone marrow transplant (BMT) is an aggressive and complex medical treatment for children with certain types of cancer and other diseases. The transplant process entails replacing the patient's diseased bone marrow with the healthy marrow of a donor. During the course of treatment, patients are isolated in their room to reduce the risk of infection. Patient's experience a variety of symptoms and side effects during the process including nausea, vomiting, diarrhea, mouth sores, fatigue, pain, discomfort, extreme muscle weakness, and emotional distress. Children often need a parent or caregiver present with them at all times throughout treatment. This process can cause significant stress and anxiety for the patient and their family. (2) Methods: This study explored the feasibility and acceptability of a patient and family directed active music making protocol during the BMT process. Ten patients, their parents, and family members participated in the study during the course of the BMT. (3) Results: Participants reported engaging in active music making 3-4 times per week and completed 121 journal forms reporting their music making experiences. They indicated using active music making to manage pain, discomfort, stress, anxiety, and boredom, foster relaxation and sleep, for enjoyment, and as a way to connect. (4) Conclusions: Patients, parents and family members reported feeling a sense of empowerment when engaged in making music to support their child or loved one.

Enhancing Resilience in Family Caregivers Using an mHealth App

BACKGROUND

We previously developed a mobile health (mHealth) app (Roadmap) to promote the resilience of family caregivers during the acute phases of care in patients undergoing hematopoietic cell transplantation (HCT).

OBJECTIVE

This study explored users' perspectives on the uptake of Roadmap's multicomponent features and the app's utility in promoting resilience.

METHODS

Fifteen participants were randomized to the full version of the app that included resilience-building activities and the other 15 were randomized to the control version that included a limited view of the app (i.e., without any resilience-building activities). They were instructed to use the app for 120 days. Semistructured qualitative interviews were then conducted with users as part of an ongoing, larger Roadmap study (NCT04094844). During the interview, caregiver participants were asked about their overall experiences with the app, frequency of use, features used, facilitators of and barriers to use, and their perspectives on its utility in promoting resilience. Data were professionally transcribed, coded, and categorized through content analysis.

RESULTS

Interviews were conducted with 30 participants, which included 23 females and 7 males. The median age of the population was 58 years (range, 23-82). The four main themes that emerged included app use, ease of use, user experiences, and ability to foster resilience. The subthemes identified related to facilitators (convenience and not harmful), barriers (caregiver burden and being too overwhelmed during the acute phases of HCT care), resilience (optimism/positivity and self-care), and app design improvements (personalization and notifications/reminders).

CONCLUSION

The qualitative evaluation provided insights into which components were utilized and how one, or a combination of the multicomponent features, may be enhancing users' experiences. Lessons learned suggest that the Roadmap app contributed to promoting resilience during the acute phases of HCT care. Nonetheless, features that provided enhanced personalization may further improve longer-term engagement.

Increasing Parent Satisfaction With Discharge Planning: An Improvement Project Using Technology in a Level 3 NICU

BACKGROUND

Neonatal intensive care unit (NICU) families are often overwhelmed by the discharge process. Their anxiety can inhibit learning and contribute to poor infant outcomes and increased healthcare utilization after discharge. Quality of the discharge teaching is the strongest predictor of discharge readiness, so NICUs must develop excellent discharge preparation programs.

PURPOSE

This improvement project enhances NICU discharge preparedness by providing consistent, early discharge teaching using technology as a supplemental resource and raises parental satisfaction with the process.

METHODS

Neonatal intensive care unit staff and former NICU parents developed a task force to create technology-based discharge education content. The content was originally uploaded to an e-book and later transferred to the electronic health record inpatient portal. Families were able to view discharge teaching content at their own convenience and pace and review topics as needed with the NICU staff. Postdischarge follow-up phone calls provided insight into parental reaction to the new education format.

RESULTS

Parent satisfaction top-box scores, reflecting the highest rating in the "Prepared for Discharge" category of the patient satisfaction survey, improved from a baseline of 47% in 2017 to 70% in 2019. Overwhelmingly, 92% of families highly rated the tablet-based discharge teaching during postdischarge phone calls.

IMPLICATIONS FOR PRACTICE

A comprehensive, consistent, and early discharge program using technology can lead to more effective and efficient NICU discharge education and improved parent satisfaction.

IMPLICATIONS FOR RESEARCH

Further studies are needed to generalize hospital-based inpatient portal teaching as an additional resource for parental education in the NICU.

Engaging Patients in the Use of Real-Time Electronic Clinical Data to Improve the Safety and Reliability of Their Own Care

OBJECTIVES

There is considerable evidence that providing patients with access to their health information is beneficial, but there is limited evidence regarding the effect of providing real-time patient safety-related information on health outcomes. The aim of this study was to evaluate the association between use of an electronic patient safety dashboard (Safety Advisor) and health outcomes.

METHODS

The Safety Advisor was implemented in 6 adult medicine units at one hospital in the United States. Study participants were asked to use the Safety Advisor, which provides real-time patient safety-related information through a Web-based portal. The primary outcome was the association between the application usage and health outcomes (readmission rate and mortality rate) per 3 different usage groups, and the secondary outcome was the association of Patient Activation Measure (PAM) scores with use.

RESULTS

One hundred eighty-one participants were included for the data analysis. Approximately 90% of users accessed the application during the first 4 days of enrollment: 51.6% of users only accessed it on 1 day, whereas 5.8% used it more than 3 days. Patients who used the application more had lower 30-day readmission rates (P = 0.01) compared with the lower-usage group. The PAM scores for users of Safety Advisor (71.8) were higher than the nonpatient portal users (60.8, P < 0.0001).

CONCLUSIONS

We found an association between the use of Safety Advisor and health outcomes. Differences in PAM scores between groups were statistically significant. A larger-scale randomized control trial is warranted to evaluate the impact on patient outcomes among a high-risk patient population.

Risk Factors for COVID-19 in College Students Identified by Physical, Mental, and Social Health Reported During the Fall 2020 Semester: Observational Study Using the Roadmap App and Fitbit Wearable Sensors

BACKGROUND

The COVID-19 pandemic triggered a seismic shift in education to web-based learning. With nearly 20 million students enrolled in colleges across the United States, the long-simmering mental health crisis in college students was likely further exacerbated by the pandemic.

OBJECTIVE

This study leveraged mobile health (mHealth) technology and sought to (1) characterize self-reported outcomes of physical, mental, and social health by COVID-19 status; (2) assess physical activity through consumer-grade wearable sensors (Fitbit); and (3) identify risk factors associated with COVID-19 positivity in a population of college students prior to release of the vaccine.

METHODS

After completing a baseline assessment (ie, at Time 0 [T0]) of demographics, mental, and social health constructs through the Roadmap 2.0 app, participants were instructed to use the app freely, wear the Fitbit, and complete subsequent assessments at T1, T2, and T3, followed by a COVID-19 assessment of history and timing of COVID-19 testing and diagnosis (T4: ~14 days after T3). Continuous measures were described using mean (SD) values, while categorical measures were summarized as n (%) values. Formal comparisons were made on the basis of COVID-19 status. The multivariate model was determined by entering all statistically significant variables (P<.05) in univariable associations at once and then removing one variable at a time through backward selection until the optimal model was obtained.

RESULTS

During the fall 2020 semester, 1997 participants consented, enrolled, and met criteria for data analyses. There was a high prevalence of anxiety, as assessed by the State Trait Anxiety Index, with moderate and severe levels in 465 (24%) and 970 (49%) students, respectively. Approximately one-third of students reported having a mental health disorder (n=656, 33%). The average daily steps recorded in this student population was approximately 6500 (mean 6474, SD 3371). Neither reported mental health nor step count were significant based on COVID-19 status (P=.52). Our analyses revealed significant associations of COVID-19 positivity with the use of marijuana and alcohol (P=.02 and P=.046, respectively) and with lower belief in public health measures (P=.003). In addition, graduate students were less likely and those with ≥20 roommates were more likely to report a COVID-19 diagnosis (P=.009).

CONCLUSIONS

Mental health problems were common in this student population. Several factors, including substance use, were associated with the risk of COVID-19. These data highlight important areas for further attention, such as prioritizing innovative strategies that address health and well-being, considering the potential long-term effects of COVID-19 on college students.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04766788; https://clinicaltrials.gov/ct2/show/NCT04766788.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/29561.

Evaluating mobile Health technology use among cancer caregivers in the digital era

Introduction

Digital health technology-based interventions have the potential to support cancer caregivers in caregiving responsibilities and in managing their own health and well-being. The objective of this study was to examine the association between caregiving characteristics and different types of digital health technologies used in a national sample of caregivers of patients undergoing hematopoietic cell transplantation (HCT).

Methods

We conducted an online, cross-sectional survey of 948 HCT caregivers.

Results

Spousal caregivers comprised nearly one-third of respondents (27.1%) with a median age of 59 years (range: 18-80 years), compared with parents (32.9%: 38 years), adult children (28.9%: 38 years), and other (11.1%; e.g. friend, other family member: 36 years). Almost two-thirds (65.4%) of all respondents reported using an app for fitness or step counting and 41.3% reported using a smartwatch. However, spousal caregivers were the least likely group to use mobile apps (0.72; P < 0.005) or smartwatches (OR = 0.46; P < 0.005) compared with parent caregivers in models adjusted for demographics and coping style. Caregiving for six months or greater was associated with the use of fewer apps compared with caregiving for less than six months in adjusted models (OR = 0.80, P < 0.005). Caregivers of patients receiving an allogeneic transplant (i.e. non-self-donor) used more apps on average than caregivers of patients receiving an autologous transplant (i.e. self-donor) in adjusted models (OR = 1.36, P < 0.005).

Conclusion

Digital health technologies reflect promising avenues for supporting cancer caregivers. While digital technologies are becoming increasingly pervasive, older caregivers remain an underserved population. Future research should integrate older adult caregivers in the co-design and development activities of technology-driven caregiver support products.

Understanding the financial and psychological impact of employment disruption among caregivers of pediatric HSCT recipients: a mixed methods analysis

PURPOSE

Pediatric hematopoietic stem cell transplantation (HSCT) confers a substantial financial burden onto patients' families. In addition to high direct medical costs, HSCTs typically require at least one caregiver to take time away from work or other responsibilities, often leading to reduced household income. Using mixed methods, we sought to understand the impact of pediatric HSCT on caregiver employment and financial need.

METHODS

We surveyed caregivers of living pediatric patients who underwent HSCT at one of two southeastern transplant centers between 2012 and 2018 (N = 95). We then interviewed a subset of caregivers (N = 18) to understand whether and how employment disruption contributed to financial distress.

RESULTS

Among caregivers surveyed, the majority of household wage earners changed their work schedules to attend medical appointments and missed workdays. This resulted in income loss for 87% of families, with 31% experiencing an income reduction of over 50%. Qualitative interviews pointed to four emergent themes: (1) employment disruption exacerbated existing financial challenges; (2) parental division of labor between caregiving and providing financially led to heightened psychological distress; (3) existing employment leave and protection resources were essential but not sufficient; and (4) the ability to work remotely and having a supportive employer facilitated employment maintenance throughout the HSCT process.

CONCLUSION

Expanded employment protections and access to accommodations are needed to limit the impact of HSCT on household income, health insurance, and financial hardship. Additionally, interventions are needed to ensure caregivers are equipped with the information necessary to navigate conversations with employers and prepare for the financial and psychological reality of employment disruption.

Provider Experiences With Offering Families Bedside Health Record Access Across a Children's Hospital

OBJECTIVES

Evaluate provider experiences with a bedside tablet inpatient portal application given to hospitalized patients and families across a children's hospital.

METHODS

In this cross-sectional study, English-speaking parents of children <12 years old and adolescents ≥12 years admitted between February and June 2017 to a 111-bed tertiary children's hospital were given an inpatient portal application (MyChart Bedside; Epic Systems Corporation, Verona, WI) on a tablet (iPad) to use during their stay. The portal included real-time vital signs, test results, medication and problem lists, a daily schedule, educational materials, and provider names and photographs. Portal use was described from electronic health record data, and provider (physician, nurse, and pharmacist) experiences were assessed from surveys.

RESULTS

Of 1892 admissions given a tablet over 5 months, 1502 (79.4%) logged in to view their inpatient health record at least once during their hospital stay. No tablets were lost or stolen. Of 101 providers, 96 completed the survey (a response rate of 95%). They reported that patients and/or parents asked them questions about information they found, including laboratory results (45% of respondents), medications (13%), diagnoses (13%), and errors and/or mistakes in care (3%). Few perceived spending more time answering questions related to portal use (8%) or that it increased their workload (11%). In all, 92% of providers wanted patients and parents to continue to be able to use the portal.

CONCLUSIONS

Almost 80% of hospitalized patients and parents given a tablet accessed real-time information from the inpatient health record. The portal facilitated communication about test results, diagnoses, and medications and providers overwhelmingly supported its ongoing use.

Evaluating health technology engagement among family caregivers of patients undergoing hematopoietic cell transplantation

Purpose:

Digital health technology-based interventions have the potential to support caregivers in their caregiving responsibilities and in managing their own health and well-being. Designing digital health technologies to support caregivers of patients undergoing hematopoietic cell transplantation requires evaluating their engagement with these technologies. The objective of this study was to examine the association between caregiving characteristics and different types of digital health technologies used.

Methods:

We conducted an online cross-sectional, national survey of 948 unpaid family caregivers of patients undergoing hematopoietic cell transplantation.

Results:

Almost two-thirds (65.4%) of respondents reported using an app for fitness or step counting, while 41.3% reported using a smartwatch. The average number of apps used was 3.3 (range 0-9). In adjusted models, adult children who were caregivers (OR=5.82, p<0.005) and caregivers of another relative (OR=2.51, p<0.005) were significantly more likely to use a fitness tracker than caregivers of a child. Caregiving for six months or greater was associated with use of fewer apps compared with caregiving for less than six months in adjusted models (OR=0.80, p<0.005). Caregivers of patients receiving an allogeneic transplant used more apps on average than caregivers of patients receiving an autologous transplant, in adjusted (OR=1.36, p<0.005) models.

Conclusion:

Digital health technologies may reflect promising avenues for supporting caregivers of patients undergoing HCT. The rapid insurgence of telehealth, propelled by the current COVID-19 pandemic, emphasizes the need for a better understanding of digital health technology for future study design.

Electronic Health Record Portal Use by Family Caregivers of Patients Undergoing Hematopoietic Cell Transplantation: United States National Survey Study

Background

As family caregivers of patients undergoing hematopoietic cell transplantation have multifaceted caregiving responsibilities (such as medical, household, financial) of long duration, they also have multiple physical, social, psychological, and informational needs.

Objective

This study explored the prevalence of electronic health record patient portal use by family caregivers for managing both their own and their hematopoietic cell transplantation care recipient’s health, as well as potential factors associated with portal use.

Methods

An electronic caregiver health survey, first developed via cognitive interviewing methods of hematopoietic cell transplantation caregivers, was distributed nationally (in the United States) by patient advocacy organizations to family caregivers of hematopoietic cell transplantation patients. It was used to assess self-reported caregiver demographics, caregiving characteristics, depression and anxiety with the Patient Health Questionnaire–4, coping with the Brief COPE, and caregiver portal use to manage care recipient’s and their own health.

Results

We found that 77% of respondents (720/937) accessed electronic health record patient portals for their care recipients, themselves, or both. Multivariate models indicated use of care recipient electronic health record portals by caregivers was more likely with young, White, married, low-income caregivers caring for a parent, residing with the care recipient, and experiencing more caregiver depression. Caregiver use of their own electronic health record portal was more likely with young, White, high-income caregivers caring for a parent and experiencing chronic medical conditions of their own. Partially due to multicollinearity, anxiety and coping did not contribute independently to this model.

Conclusions

Findings from the survey could open avenues for future research into caregiver use of technology for informational support or intervention, including wearables and mobile health.

International Registered Report Identifier (IRRID)

RR2-10.2196/4918

Quantifying Patient Portal Use: Systematic Review of Utilization Metrics

BACKGROUND

Use of patient portals has been associated with positive outcomes in patient engagement and satisfaction. Portal studies have also connected portal use, as well as the nature of users' interactions with portals, and the contents of their generated data to meaningful cost and quality outcomes. Incentive programs in the United States have encouraged uptake of health information technology, including patient portals, by setting standards for meaningful use of such technology. However, despite widespread interest in patient portal use and adoption, studies on patient portals differ in actual metrics used to operationalize and track utilization, leading to unsystematic and incommensurable characterizations of use. No known review has systematically assessed the measurements used to investigate patient portal utilization.

OBJECTIVE

The objective of this study was to apply systematic review criteria to identify and compare methods for quantifying and reporting patient portal use.

METHODS

Original studies with quantifiable metrics of portal use published in English between 2014 and the search date of October 17, 2018, were obtained from PubMed using the Medical Subject Heading term "Patient Portals" and related keyword searches. The first search round included full text review of all results to confirm a priori data charting elements of interest and suggest additional categories inductively; this round was supplemented by the retrieval of works cited in systematic reviews (based on title screening of all citations). An additional search round included broader keywords identified during the full-text review of the first round. Second round results were screened at abstract level for inclusion and confirmed by at least two raters. Included studies were analyzed for metrics related to basic use/adoption, frequency of use, duration metrics, intensity of use, and stratification of users into "super user" or high utilizers. Additional categories related to provider (including care team/administrative) use of the portal were identified inductively. Additional analyses included metrics aligned with meaningful use stage 2 (MU-2) categories employed by the US Centers for Medicare and Medicaid Services and the association between the number of portal metrics examined and the number of citations and the journal impact factor.

RESULTS

Of 315 distinct search results, 87 met the inclusion criteria. Of the a priori metrics, plus provider use, most studies included either three (26 studies, 30%) or four (23 studies, 26%) metrics. Nine studies (10%) only reported the patient use/adoption metric and only one study (1%) reported all six metrics. Of the US-based studies (n=76), 18 (24%) were explicitly motivated by MU-2 compliance; 40 studies (53%) at least mentioned these incentives, but only 6 studies (8%) presented metrics from which compliance rates could be inferred. Finally, the number of metrics examined was not associated with either the number of citations or the publishing journal's impact factor.

CONCLUSIONS

Portal utilization measures in the research literature can fall below established standards for "meaningful" or they can substantively exceed those standards in the type and number of utilization properties measured. Understanding how patient portal use has been defined and operationalized may encourage more consistent, well-defined, and perhaps more meaningful standards for utilization, informing future portal development.

What Do Patients and Caregivers Want? A Systematic Review of User Suggestions to Improve Patient Portals

Significant investments have been made in patient portals in order to provide patients with greater access to their medical records, as well as to other services such as secure electronic communication with their healthcare provider(s). Unfortunately, overall, patient adoption and use of patient portals has been lower than expected. According to the user-centered design philosophy, including end-user voices in all stages of the design process is critical to a technology's success. Thus, as a part of a larger systematic review, we examined the patient portal literature and identified 42 studies that reported patient's or their caregiver's suggestions to improve patient portals. The results suggest that patients and caregivers want patient portals to (i) support human connection (e.g., virtual patient-provider interactions), (ii) give patients more control (e.g., over their medical record) and be designedfor the variation in patient and caregiver experiences, and (iii) be innovative (e.g., provide contextualized medical advice).

Harnessing mobile health technology to support long-term chronic illness management: exploring family caregiver support needs in the outpatient setting

OBJECTIVE

Family caregiving is an important public health issue, particularly with the aging population. In recent years, mobile health (mHealth) technology has emerged as a potential low-cost, scalable platform to address caregiver support needs, and thereby alleviate the burden on caregivers. This study sought to examine the support needs of family caregivers in their lived experiences of outpatient care to inform the development of a future mHealth intervention.

MATERAILS AND METHODS

We conducted 20 semi-structured interviews in 2 outpatient hematopoietic cell transplant (HCT) clinics at a large academic medical center in the Midwestern United States. A thematic analysis was performed to define emerging themes.

RESULTS

Qualitative data analysis identified 5 primary themes that HCT caregivers faced: (I) lifestyle restrictions due to the patient's immunocompromised state; (II) Unmet needs due to limitations in the current resources, including unfamiliar medical tasks without necessary trainings; and (III) caregivers' adaptive strategies, including reformation of social relationships with family and friends. Based on these findings, we suggest 3 design considerations to guide the development of a future mHealth intervention.

CONCLUSIONS

The findings herein captured the family caregiver's lived experiences during outpatient care. There was broad agreement that caregiving was challenging and stressful. Thus, effective and scalable interventions to support caregivers are needed. This study provided data to guide the content and design of a future mHealth intervention in the outpatient setting.

Promoting Health and Well-Being Through Mobile Health Technology (Roadmap 2.0) in Family Caregivers and Patients Undergoing Hematopoietic Stem Cell Transplantation: Protocol for the Development of a Mobile Randomized Controlled Trial

Background

Cancer patients who undergo allogeneic hematopoietic stem cell transplantation are among the most medically fragile patient populations with extreme demands for caregivers. Indeed, with earlier hospital discharges, the demands placed on caregivers continue to intensify. Moreover, an increased number of allogeneic hematopoietic stem cell transplantations are being performed worldwide, and this expensive procedure has significant economic consequences. Thus, the health and well-being of family caregivers have attracted widespread attention. Mobile health technology has been shown to deliver flexible, and time- and cost-sparing interventions to support family caregivers across the care trajectory.

Objective

This protocol aims to leverage technology to deliver a novel caregiver-facing mobile health intervention named Roadmap 2.0. We will evaluate the effectiveness of Roadmap 2.0 in family caregivers of patients undergoing hematopoietic stem cell transplantation.

Methods

The Roadmap 2.0 intervention will consist of a mobile randomized trial comparing a positive psychology intervention arm with a control arm in family caregiver-patient dyads. The primary outcome will be caregiver health-related quality of life, as assessed by the PROMIS Global Health scale at day 120 post-transplant. Secondary outcomes will include other PROMIS caregiver- and patient-reported outcomes, including companionship, self-efficacy for managing symptoms, self-efficacy for managing daily activities, positive affect and well-being, sleep disturbance, depression, and anxiety. Semistructured qualitative interviews will be conducted among participants at the completion of the study. We will also measure objective physiological markers (eg, sleep, activity, heart rate) through wearable wrist sensors and health care utilization data through electronic health records.

Results

We plan to enroll 166 family caregiver-patient dyads for the full data analysis. The study has received Institutional Review Board approval as well as Code Review and Information Assurance approval from our health information technology services. Owing to the COVID-19 pandemic, the study has been briefly put on hold. However, recruitment began in August 2020. We have converted all recruitment, enrollment, and onboarding processes to be conducted remotely through video telehealth. Consent will be obtained electronically through the Roadmap 2.0 app.

Conclusions

This mobile randomized trial will determine if positive psychology-based activities delivered through mobile health technology can improve caregiver health-related quality of life over a 16-week study period. This study will provide additional data on the effects of wearable wrist sensors on caregiver and patient self-report outcomes.

Trial Registration

ClinicalTrials.gov NCT04094844; https://www.clinicaltrials.gov/ct2/show/NCT04094844

International Registered Report Identifier (IRRID)

PRR1-10.2196/19288

Health Information Technology Utilization by Adolescent and Young Adult Aged Inpatients Undergoing Hematopoietic Cell Transplantation

This longitudinal study examined feasibility of "Roadmap 1.0," a modular health information application integrated with the electronic medical record, provided to 30 adolescent and young adult (AYA) inpatients 11-24 years of age undergoing hematopoietic stem cell transplantation (HSCT). Feasibility was demonstrated: 70% accessed the application. Utilization was highest the first 2 weeks of hospitalization, with the laboratory results module used most. Users' tension and fatigue were higher than nonusers' at baseline, but not hospital discharge or day 100. Results suggest AYAs utilize health information technology in ways consistent with the HSCT trajectory and Roadmap 1.0 addressed informational and psychological needs.

Parent Perceptions of Real-time Access to Their Hospitalized Child's Medical Records Using an Inpatient Portal: A Qualitative Study

BACKGROUND AND OBJECTIVES

Engaging with parents in care improves pediatric care quality and patient safety; however, parents of hospitalized children often lack the information necessary to effectively participate. To enhance engagement, some hospitals now provide parents with real-time online access to information from their child's inpatient medical record during hospitalization. Whether these "inpatient portals" provide benefits for parents of hospitalized children is unknown. Our objectives were to identify why parents used an inpatient portal application on a tablet computer during their child's hospitalization and identify their perspectives of ways to optimize the technology.

METHODS

Semistructured in-person interviews were conducted with 14 parents who were given a tablet computer with a commercially available inpatient portal application for use throughout their child's hospitalization. The portal included vital signs, diagnoses, medications, laboratory test results, patients' schedule, messaging, education, and provider pictures and/or roles. Interviews were audio recorded and transcribed and continued until reaching thematic saturation. Three researchers used an inductive approach to identify emergent themes regarding why parents used the portal.

RESULTS

Five themes emerged regarding parent motivations for accessing information within the portal: (1) monitoring progress, (2) feeling empowered and/or relying less on staff, (3) facilitating rounding communication and/or decision-making, (4) ensuring information accuracy and/or providing reassurance, and (5) aiding memory. Parents recommended that the hospital continue to offer the portal and expand it to allow parents to answer admission questions, provide feedback, and access doctors' daily notes.

CONCLUSIONS

Providing parents with real-time clinical information during their child's hospitalization using an inpatient portal may enhance their ability to engage in caregiving tasks critical to ensuring inpatient care quality and safety.

Online interventions geared toward increasing resilience and reducing distress in family caregivers

PURPOSE OF REVIEW

Family caregivers of patients with cancer often spend a great deal of effort on physically and emotionally demanding work while taking care of patients. However, the majority of caregivers are not properly equipped for their role as caregivers, which may lead to increased distress in both caregivers and patients. Herein, we reviewed the recent literature (last 3 years) examining online interventions that seek to support caregiver resilience and decrease distress.

RECENT FINDINGS

Our search identified interventions involving three main themes: informational support, positive activities, and social support. These are mostly in the form of web-based tools and mobile apps targeting both usability and quality of life. Social network services are also considered in this review as a new environment for caregivers to connect with other individuals with lived experience in similar circumstances.

SUMMARY

Existing studies on online interventions to support caregivers is still at a formative development stage and pilot tests of feasibility, rather than a substantive body of randomized controlled trials to assess the impact in different user populations, or to determine specific factors that impact caregiver distress level or resilience. More research is needed to further assess the long-term effects of online interventions on caregiver stress and resilience. Also, the role of different types of social network services and new forms of interaction, such as conversational agents, has not yet been fully investigated in caregiver populations. Future research should strive to seek new modes of providing services that may present novel opportunities to enhance caregiver resilience and reduce distress.

Development of a National Caregiver Health Survey for Hematopoietic Stem Cell Transplant: Qualitative Study of Cognitive Interviews and Verbal Probing

Background

Roadmap 1.0 is a mobile health app that was previously developed for caregivers of patients who have undergone hematopoietic stem cell transplantation (HSCT). Formative research targeted toward its end users (caregivers) can help inform app design and development, allowing additional components to be incorporated into the app, which can then be tested in a future randomized controlled trial.

Objective

This study aimed to create a methodologically rigorous national survey that would help inform the development of Roadmap 2.0.

Methods

We conducted a prospective, qualitative research study that took place between November 18, 2018, and February 7, 2019, in a blood and marrow transplant unit within a large academic medical institution in the midwestern part of the United States. Cognitive interviews, including think-aloud and verbal probing techniques, were conducted in 10 adult caregivers (≥18 years) of patients who had undergone HSCT.

Results

Most participants were female (9/10, 90%), white (9/10, 90%), married (9/10, 90%), employed at least part time (6/10, 60%), caregivers of adult patients (7/10, 70%), and had some college education (9/10, 90%) and an annual household income of $60,000 or higher (6/10, 60%). All but one interview was audio-recorded, with permission. Overall, participants were engaged in the cognitive interview process of the draft survey, which included 7 topics. The interviews highlighted areas wherein survey items could be further refined, such as offering more response choices (eg, “NA”) or clarifying the type of transplant (eg, autologous or allogeneic) or context of transplant care (eg, pre-HSCT, during HSCT, post-HSCT, inpatient, and outpatient). Apart from these findings, the items in demographics, caregiving experiences, technology, positive activities, and mood were generally interpreted as intended. On the basis of the transcript data and field notes by the interviewer, items within self-efficacy (Caregiver Self-Efficacy Scale) and coping (Brief Coping Orientation to Problems Experienced inventory) questionnaires generated more confusion among interviewer and participants, reflecting difficulties in interpreting the meaning of some survey items.

Conclusions

This study incorporated the four cognitive aspects of survey methodology that describe the question-answering process—(1) comprehension, (2) information retrieval, (3) judgment and decision making, and (4) responding—by using the think-aloud and probing techniques in cognitive interviews. We conclude that this methodologically rigorous process informed revisions and improved our final questionnaire design.

International Registered Report Identifier (IRRID)

RR2-10.2196/resprot.49188

Promise of Mobile Health Technology to Reduce Disparities in Patients With Cancer and Survivors

Despite recent advances in cancer control, numerous disparities exist in the areas of patient access to care, self-management, and quality of life. However, mobile health technology shows promise as a tool to reduce disparities among patients with cancer and cancer survivors by overcoming such barriers as limited access to providers, difficulty communicating with providers, and inadequate communication between patients and providers regarding symptoms. This narrative review draws on the literature in cancer and noncancer populations to identify factors that create or maintain disparities and to describe opportunities for mobile health technology to reduce disparities.

Novel Health Information Technology Tool Use by Adult Patients Undergoing Allogeneic Hematopoietic Cell Transplantation: Longitudinal Quantitative and Qualitative Patient-Reported Outcomes

Purpose

Health information technology (IT) is an ideal medium to improve the delivery of patient-centered care and increase patient engagement. Health IT interventions should be designed with the end user in mind and be specific to the needs of a given population. Hematopoietic cell transplantation (HCT), commonly referred to as blood and marrow transplantation (BMT), is a prime example of a complex medical procedure where patient-caregiver-provider engagement is central to a safe and successful outcome. We have previously reported on the design and development of an HCT-specific health IT tool, BMT Roadmap.

Methods

This study highlights longitudinal quantitative and qualitative patient-reported outcomes (PROs) in 20 adult patients undergoing allogeneic HCT. Patients completed PROs at three time points (baseline, day 30 post-HTC, and day 100 post-HCT) and provided weekly qualitative data through semistructured interviews while using BMT Roadmap.

Results

The mean hospital stay was 23.3 days (range, 17 to 37 days), and patients had access to BMT Roadmap for a mean of 21.3 days (range, 15 to 37 days). The total time spent on BMT Roadmap ranged from 0 to 139 minutes per patient, with a mean of 55 minutes (standard deviation, 47.6 minutes). We found that patients readily engaged with the tool and completed qualitative interviews and quantitative PROs. The Patient Activation Measure, a validated measure of patient engagement, increased for patients from baseline to discharge and day 100. Activation was significantly and negatively correlated with depression and anxiety PROs at discharge, suggesting that this may be an important time point for intervention.

Conclusion

Given the feasibility and promising results reported in this study, next steps include expanding our current health IT platform and implementing a randomized trial to assess the impact of BMT Roadmap on critical PROs.

The Use of a Video for Discharge Education for Parents After Pediatric Stem Cell Transplantation

Background: Caring for a child at home after hematopoietic stem cell transplant (HSCT) is challenging for parents, and discharge education is critical to ensure parents are prepared. The purpose of this study is to evaluate the feasibility and effectiveness of a discharge video intervention (DVI) as an adjunct to standard discharge teaching (SDT). Method: A two-phase study was conducted at an urban children’s hospital in the western United States. Phase 1 involved SDT alone followed by nurse-administered proficiency testing of parent knowledge in caring for their children at home using a 4-point Likert-type scale of parents of children post-allogeneic HSCT. These results informed the DVI, created in English and Spanish in Phase 2. The DVI content included topics on home cleaning, notifying the medical team, graft-versus-host disease (GVHD), diet and visitor restrictions, and outpatient visits. In Phase 2, the DVI was viewable by parents who also received SDT. Parents’ proficiency was evaluated using the same procedure as in Phase 1. Results: Thirty-four parents participated: 17 in Phase 1 (SDT), 17 in Phase 2 (SDT + DVI). The DVI was viewed by parents in Phase 2 approximately twice prior to discharge. Parents in Phase 2 had higher proficiency scores on home cleaning, signs/symptoms of GVHD, and diet restriction. Parents in Phase 1 had higher proficiency regarding notifying the team. Conclusions: The DVI was feasible and demonstrated incremental increases in parent’s proficiency related to some discharge topics.

Technology Access, Technical Assistance, and Disparities in Inpatient Portal Use

BACKGROUND

Disadvantaged populations, including minorities and the elderly, use patient portals less often than relatively more advantaged populations. Limited access to and experience with technology contribute to these disparities. Free access to devices, the Internet, and technical assistance may eliminate disparities in portal use.

OBJECTIVE

To examine predictors of frequent versus infrequent portal use among hospitalized patients who received free access to an iPad, the Internet, and technical assistance.

MATERIALS AND METHODS

This subgroup analysis includes 146 intervention-arm participants from a pragmatic randomized controlled trial of an inpatient portal. The participants received free access to an iPad and inpatient portal while hospitalized on medical and surgical cardiac units, together with hands-on help using them. We used logistic regression to identify characteristics predictive of frequent use.

RESULTS

More technology experience (adjusted odds ratio [OR] = 5.39, p = 0.049), less severe illness (adjusted OR = 2.07, p = 0.077), and private insurance (adjusted OR = 2.25, p = 0.043) predicted frequent use, with a predictive performance (area under the curve) of 65.6%. No significant differences in age, gender, race, ethnicity, level of education, employment status, or patient activation existed between the frequent and infrequent users in bivariate analyses. Significantly more frequent users noticed medical errors during their hospital stay.

DISCUSSION AND CONCLUSION

Portal use was not associated with several sociodemographic characteristics previously found to limit use in the inpatient setting. However, limited technology experience and high illness severity were still barriers to frequent use. Future work should explore additional strategies, such as enrolling health care proxies and improving usability, to reduce potential disparities in portal use.

Providers' Perspectives on Sharing Health Information through Acute Care Patient Portals

Engaging healthcare providers in acute care patient portal implementation is critical to ensure productive use. However, few studies have assessed provider's perceptions of an acute care portal after implementation. In this study, we surveyed 63 nurses, physicians, and physician assistants following a 3-year randomized trial of an acute care portal. The survey assessed providers' perceptions of the portal and its impact on care delivery. Respondents reported that the portal positively impacted care, and they perceived that their patients found it usable and trustworthy. Respondents reported that all the portal's features were useful, especially the display of laboratory test results. Compared with the results of a patient survey, providers underestimated the portal's usefulness to patients, and ranked features as very useful significantly less often than patients (57% vs. 74%; p<0.001). Our study found that providers supported their patients' use of the portal, but may have underappreciated the portal's value to patients.

Impact of a health information technology tool addressing information needs of caregivers of adult and pediatric hematopoietic stem cell transplantation patients

PURPOSE

We developed BMT Roadmap, a health information technology (HIT) application on a tablet, to address caregivers' unmet needs with patient-specific information from the electronic health record. We conducted a preliminary feasibility study of BMT Roadmap in caregivers of adult and pediatric HSCT patients. The study was registered on ClinicalTrials.gov (NCT03161665; NCT02409121).

METHODS

BMT Roadmap was delivered to 39 caregivers of adult and pediatric patients undergoing first-time HSCT at a single study site. We assessed person-reported outcome measures (PROMs) at baseline (hospital admission), discharge, and day 100: usefulness of BMT Roadmap (Perceived Usefulness); activation (Patient Activation Measure-Caregiver version [PAM-C]); mental health ([POMS-2®]: depression, distress, vigor, and fatigue); anxiety (State-Trait Anxiety Inventory); and quality of life (Caregiver Quality of Life Index-Cancer [CQOLC]). To identify determinants of caregiver activation and quality of life, we used linear mixed models.

RESULTS

BMT Roadmap was perceived useful and activation increased from baseline to discharge (p = 0.001). Further, burden decreased through discharge (p = 0.007). Overall, a pattern of increasing vigor and decreasing depression, distress, fatigue, and anxiety was apparent from baseline to discharge. However, overall quality of life lowered at discharge after accounting for BMT Roadmap use, depression, anxiety, and fatigue (p = 0.04).

CONCLUSIONS

BMT Roadmap was a feasible HIT intervention to implement in HSCT caregivers. BMT Roadmap was associated with increased activation and decreased burden, but quality of life lowered across hospitalization. Findings support the need to further develop caregiver-specific self-directed resources and provide them both inpatient and outpatient across the HSCT trajectory.

Patient portal adoption and use by hospitalized cancer patients: a retrospective study of its impact on adverse events, utilization, and patient satisfaction

BACKGROUND

Portal use has been studied among outpatients, but its utility and impact on inpatients is unclear. This study describes portal adoption and use among hospitalized cancer patients and investigates associations with selected safety, utilization, and satisfaction measures.

METHODS

A retrospective review of 4594 adult hospitalized cancer patients was conducted between 2012 and 2014 at Mayo Clinic in Jacksonville, Florida, comparing portal adopters, who registered for a portal account prior to hospitalization, with nonadopters. Adopters were classified by their portal activity during hospitalization as active or inactive inpatient users. Univariate and several logistic and linear regression models were used for analysis.

RESULTS

Of total patients, 2352 (51.2%) were portal adopters, and of them, 632 (26.8%) were active inpatient users. Portal adoption was associated with patients who were young, female, married, with higher income, and had more frequent hospitalizations (P < .05). Active inpatient use was associated with patients who were young, married, nonlocals, with higher disease severity, and were hospitalized for medical treatment (P < .05). In univariate analyses, self-management knowledge scores were higher among adopters vs nonadopters (84.3 and 80.0, respectively; P = .01) and among active vs inactive inpatient users (87.0 and 83.3, respectively; P = .04). In regression models adjusted for age and disease severity, the association between portal behaviors and majority of measures were not significant (P > .05).

CONCLUSIONS

Over half of our cancer inpatients adopted a portal prior to hospitalization, with increased adoption associated with predisposing and enabling determinants (eg: age, sex, marital status, income), and increased inpatient use associated with need (eg: nonlocal residence and disease severity). Additional research and greater effort to expand the portal functionality is needed to impact inpatient outcomes.

Supporting Caregivers of Patients With Cancer: A Summary of Technology-Mediated Interventions and Future Directions

This paper aims to review literature published on the support of cancer caregivers with health technology. Eighteen articles were reviewed to better understand cancer caregiving and categorized into four different themes: (1) design guidelines, (2) information facilitation, (3) social support, and (4) multicomponent interventions. Analysis of the current articles revealed that there are substantial gaps in knowledge regarding a range of health technologies that facilitate family caregiver support and its distribution to health institutions. Further research is needed in this area, as family caregivers are primary providers of essential elements of care to patients. Future studies should unpack existing barriers that interfere with the development of health technology interventions in cancer care.

Sharing Clinical Notes with Hospitalized Patients via an Acute Care Portal

Though several institutions offer hospitalized patients access to their medical records through acute care patient portals, no studies have assessed the potential impact of patients' access to physicians' notes through these systems. We employed a mixed-methods approach, including patient surveys, system usage log analysis, and qualitative interviews, to describe patients' perspectives on receiving their clinical notes and usage of the clinical notes feature in an acute care patient portal. Patients visited the clinical notes feature more frequently and for longer durations than any other feature. In qualitative interviews, patients reported improved access to information, better insight into their conditions, decreased anxiety, increased appreciation for clinicians, improvements in health behaviors, and more engagement in care. Our results suggest that sharing notes with hospitalized patients is feasible and beneficial, although further studies should investigate the magnitude of benefit and explore the unintended negative consequences associated with increased transparency of clinical information.

Implementation of acute care patient portals: recommendations on utility and use from six early adopters

Objective

To provide recommendations on how to most effectively implement advanced features of acute care patient portals, including: (1) patient-provider communication, (2) care plan information, (3) clinical data viewing, (4) patient education, (5) patient safety, (6) caregiver access, and (7) hospital amenities.

Recommendations

We summarize the experiences of 6 organizations that have implemented acute care portals, representing a variety of settings and technologies. We discuss the considerations for and challenges of incorporating various features into an acute care patient portal, and extract the lessons learned from each institution's experience. We recommend that stakeholders in acute care patient portals should: (1) consider the benefits and challenges of generic and structured electronic care team messaging; (2) examine strategies to provide rich care plan information, such as daily schedule, problem list, care goals, discharge criteria, and post-hospitalization care plan; (3) offer increasingly comprehensive access to clinical data and medical record information; (4) develop alternative strategies for patient education that go beyond infobuttons; (5) focus on improving patient safety through explicit safety-oriented features; (6) consider strategies to engage patient caregivers through portals while remaining cognizant of potential Health Insurance Portability and Accountability Act (HIPAA) violations; (7) consider offering amenities to patients through acute care portals, such as information about navigating the hospital or electronic food ordering.