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Czuber NK, Garabedian PM, Rice H, Tejeda CJ, Dykes PC, Latham NK. Human-Centered Design and Development of a Fall Prevention Exercise App for Older Adults in Primary Care Settings. Appl Clin Inform 2024; 15:544-555. [PMID: 38350643 PMCID: PMC11236445 DOI: 10.1055/a-2267-1727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 01/22/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Falls in older adults are a serious public health problem that can lead to reduced quality of life or death. Patients often do not receive fall prevention guidance from primary care providers (PCPs), despite evidence that falls can be prevented. Mobile health technologies may help to address this disparity and promote evidence-based fall prevention. OBJECTIVE Our main objective was to use human-centered design to develop a user-friendly, fall prevention exercise app using validated user requirements. The app features evidence-based behavior change strategies and exercise content to support older people initiating and adhering to a progressive fall prevention exercise program. METHODS We organized our multistage, iterative design process into three phases: gathering user requirements, usability evaluation, and refining app features. Our methods include focus groups, usability testing, and subject-matter expert meetings. RESULTS Focus groups (total n = 6), usability testing (n = 30) including a posttest questionnaire [Health-ITUES score: mean (standard deviation [SD]) = 4.2 (0.9)], and subject-matter expert meetings demonstrate participant satisfaction with the app concept and design. Overall, participants saw value in receiving exercise prescriptions from the app that would be recommended by their PCP and reported satisfaction with the content of the app. CONCLUSION This study demonstrates the development, refinement, and usability testing of a fall prevention exercise app and corresponding tools that PCPs may use to prescribe tailored exercise recommendations to their older patients as an evidence-based fall prevention strategy accessible in the context of busy clinical workflows.
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Affiliation(s)
- Nichole K. Czuber
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Pamela M. Garabedian
- Clinical and Quality Analysis, Mass General Brigham, Inc., Boston, Massachusetts, United States
| | - Hannah Rice
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Christian J. Tejeda
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Patricia C. Dykes
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States
| | - Nancy K. Latham
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States
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Takase M, Kisanuki N, Nakayoshi Y, Uemura C, Sato Y, Yamamoto M. Exploring nurses' clinical judgment concerning the relative importance of fall risk factors: A mixed method approach using the Q Methodology. Int J Nurs Stud 2024; 153:104720. [PMID: 38408403 DOI: 10.1016/j.ijnurstu.2024.104720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 02/04/2024] [Accepted: 02/08/2024] [Indexed: 02/28/2024]
Abstract
BACKGROUND Nurses are pivotal in averting patient falls through their assessment of cues presented by patients and their environments, rendering clinical judgments regarding the risk of falling, and implementing tailored interventions. Despite the intricate cognitive processes entailed in nurses' judgment, no prior studies have explored their approach to assessing the risk of falling. OBJECTIVE This study aimed to examine how nurses judge the risk of falling among patients with different conditions, whether there are differences in the importance of risk factors as judged by nurses, how they justify their judgments, and what attributes of the nurses influence their judgments. DESIGN A mixed method approach using the Q Methodology was employed. SETTING(S) Three public and private hospitals in Japan. PARTICIPANTS Eighteen nurses participated in the study. METHODS Participants were tasked with ranking 36 patient scenarios, each featuring a distinct set of fall risk factors. Subsequently, post-sorting interviews were conducted to gather insights into their typical approach to assessing fall risk and the rationale behind their ranking decisions. A by-person principal component factor extraction was employed to examine differences in the rankings of the scenarios. The interview data were analyzed descriptively to elucidate the reasons behind these discrepancies. RESULTS Nurses engage in complex cognitive manipulations when evaluating the risk of patient falls, drawing extensively from their wealth of experience while utilizing assessment tools to support their judgments. In essence, nurses identify patients' tendency to act alone without calling a nurse, impaired gait and cognition, sedative use, drains, and limited information sharing among healthcare professionals as key fall risks. In addition, nurses vary in the importance they attribute to certain risk factors, leading to the discrimination of three distinct judgment profiles. One group of nurses judges patients with cognitive impairment and acting alone as high risk. Another group of nurses considers patients with unstable gait and acting alone as high risk. The last group of nurses sees patients wearing slippers as high risk. The post-sorting interviews revealed that their judgments are closely related to the healthcare context and patient population. CONCLUSIONS Nurses operate within diverse contexts, wherein they interact with patients of varying characteristics, collaborate with professionals from diverse disciplines, and have access to varying levels of human and physical resources. This nuanced understanding empowers the formulation of judgments that are finely attuned to the specific context at hand. STUDY REGISTRATION Not registered.
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Affiliation(s)
- Miyuki Takase
- School of Nursing, Yasuda Women's University, Hiroshima, Japan.
| | - Naomi Kisanuki
- School of Nursing, Yasuda Women's University, Hiroshima, Japan
| | - Yoko Nakayoshi
- School of Nursing, Yasuda Women's University, Hiroshima, Japan
| | - Chizuru Uemura
- School of Nursing, Yasuda Women's University, Hiroshima, Japan
| | - Yoko Sato
- Division of Nursing, Hiroshima University Hospital, Hiroshima, Japan
| | - Masako Yamamoto
- School of Nursing, Yasuda Women's University, Hiroshima, Japan
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Tejeda CJ, Garabedian PM, Rice H, Samal L, Latham NK, Dykes PC. Development and Usability Testing of an Exercise-Based Primary Care Fall Prevention Clinical Decision Support Tool. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2024; 2023:699-708. [PMID: 38222393 PMCID: PMC10785844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
For older patients, falls are the leading cause offatal and nonfatal injuries. Guidelines recommend that at-risk older adults are referred to appropriate fall-prevention exercise programs, but many do not receive support for fall-risk management in the primary care setting. Advances in health information technology may be able to address this gap. This article describes the development and usability testing of a clinical decision support (CDS) tool for fall prevention exercise. Using rapid qualitative analysis and human-centered design, our team developed and tested the usability of our CDS prototype with primary care team members. Across 31 Health-Information Technology Usability Evaluation Scale surveys, our CDS prototype received a median score of 5.0, mean (SD) of 4.5 (0.8), and a range of 4.1-4.9. This study highlights the features and usability offall prevention CDS for helping primary care providers deliver patient-centeredfall prevention care.
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Kiyoshi-Teo H, McMahon SK, Northup-Snyder K, Cohen DJ. Older People's Descriptions of Their Engagement in Fall Prevention. West J Nurs Res 2024; 46:10-18. [PMID: 37950361 DOI: 10.1177/01939459231211803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Evidence-based strategies to decrease fall rates are well established. However, little is understood about how older people engage in fall prevention strategies. Motivational Interviewing (MI) sessions aimed to facilitate individuals' engagement in fall prevention can be analyzed to learn what it means for older people to engage in fall prevention. Thus, the purpose of this study was to explore how older people describe their engagement in fall prevention. Participants in our parent project, MI for Fall Prevention (MI-FP), who received MI sessions were purposively selected for maximum variation in age, sex, fall risks, and MI specialist assigned. The first (of 8) MI sessions from 16 participants were recorded, transcribed, and analyzed using qualitative content analysis. Three researchers first deductively analyzed fall prevention strategies that participants described using an evidence-based fall prevention guideline as a reference. Then, we inductively analyzed the characteristics of these strategies and how participants engaged in them. Finally, we used the Capability, Opportunity, Motivation, Behavior (COM-B) model to organize our results about factors influencing engagement. We found (1) older adults engage in unique combinations of fall prevention strategies and (2) decisions about engagement in fall prevention strategies were influenced by multiple factors that were personal (e.g., who I am, capability, motivation, and opportunities). This study highlighted how fall prevention can be a life-long lifestyle decision for older people. Understanding older people's perspectives about engaging in fall prevention is essential to develop interventions to promote evidence-based fall prevention strategies in real-world settings.
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Affiliation(s)
- Hiroko Kiyoshi-Teo
- School of Nursing, Oregon Health & Science University, Portland, OR, USA
| | | | | | - Deborah J Cohen
- School of Medicine, Oregon Health & Science University, Portland, OR, USA
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Shear K, Rice H, Garabedian PM, Bjarnadottir R, Lathum N, Horgas AL, Harle CA, Dykes PC, Lucero R. Management of Fall Risk Among Older Adults in Diverse Primary Care Settings. J Appl Gerontol 2023; 42:2219-2232. [PMID: 37387449 PMCID: PMC10782546 DOI: 10.1177/07334648231185757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023] Open
Abstract
OBJECTIVES Falls are persistent among community-dwelling older adults despite existing prevention guidelines. We described how urban and rural primary care staff and older adults manage fall risk and factors important to integration of computerized clinical decision support (CCDS). METHODS Interviews, contextual inquiries, and workflow observations were analyzed using content analysis and synthesized into a journey map. Sociotechnical and PRISM domains were applied to identify workflow factors important to sustainable CCDS integration. RESULTS Participants valued fall prevention and described similar approaches. Available resources differed between rural and urban locations. Participants wanted evidence-based guidance integrated into workflows to bridge skills gaps. DISCUSSION Sites described similar clinical approaches with differences in resource availability. This implies that a single intervention would need to be flexible to environments with differing resources. Electronic Health Record's inherent ability to provide tailored CCDS is limited. However, CCDS middleware could integrate into different settings and increase evidence use.
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Affiliation(s)
- Kristen Shear
- Department of Family, Community, and Health Systems Science, College of Nursing, University of Florida, Gainesville, FL, USA
- Center for Nursing Science and Clinical Inquiry, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Hannah Rice
- Harvard Medical School, Brigham and Women’s Hospital, Boston, MA, USA
- BWH Center for Patient Safety, Research and Practice, Boston, MA, USA
| | | | - Ragnhildur Bjarnadottir
- Department of Family, Community, and Health Systems Science, College of Nursing, University of Florida, Gainesville, FL, USA
| | - Nancy Lathum
- Harvard Medical School, Brigham and Women’s Hospital, Boston, MA, USA
| | - Ann L. Horgas
- Department of Biobehavioral Nursing Science, College of Nursing, University of Florida, Gainesville, FL, USA
| | - Christopher A. Harle
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Patricia C. Dykes
- Harvard Medical School, Brigham and Women’s Hospital, Boston, MA, USA
- BWH Center for Patient Safety, Research and Practice, Boston, MA, USA
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Miller SD, Murphy Z, Gray JH, Marsteller J, Oliva-Hemker M, Maslen A, Lehmann HP, Nagy P, Hutfless S, Gurses AP. Human-Centered Design of a Clinical Decision Support for Anemia Screening in Children with Inflammatory Bowel Disease. Appl Clin Inform 2023; 14:345-353. [PMID: 36809791 PMCID: PMC10171996 DOI: 10.1055/a-2040-0578] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 02/17/2023] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND Inflammatory bowel disease (IBD) commonly leads to iron deficiency anemia (IDA). Rates of screening and treatment of IDA are often low. A clinical decision support system (CDSS) embedded in an electronic health record could improve adherence to evidence-based care. Rates of CDSS adoption are often low due to poor usability and fit with work processes. One solution is to use human-centered design (HCD), which designs CDSS based on identified user needs and context of use and evaluates prototypes for usefulness and usability. OBJECTIVES this study aimed to use HCD to design a CDSS tool called the IBD Anemia Diagnosis Tool, IADx. METHODS Interviews with IBD practitioners informed creation of a process map of anemia care that was used by an interdisciplinary team that used HCD principles to create a prototype CDSS. The prototype was iteratively tested with "Think Aloud" usability evaluation with clinicians as well as semi-structured interviews, a survey, and observations. Feedback was coded and informed redesign. RESULTS Process mapping showed that IADx should function at in-person encounters and asynchronous laboratory review. Clinicians desired full automation of clinical information acquisition such as laboratory trends and analysis such as calculation of iron deficit, less automation of clinical decision selection such as laboratory ordering, and no automation of action implementation such as signing medication orders. Providers preferred an interruptive alert over a noninterruptive reminder. CONCLUSION Providers preferred an interruptive alert, perhaps due to the low likelihood of noticing a noninterruptive advisory. High levels of desire for automation of information acquisition and analysis with less automation of decision selection and action may be generalizable to other CDSSs designed for chronic disease management. This underlines the ways in which CDSSs have the potential to augment rather than replace provider cognitive work.
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Affiliation(s)
- Steven D. Miller
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Zachary Murphy
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Joshua H. Gray
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Jill Marsteller
- Department of Health Policy and Management, Johns Hopkins University School of Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, Maryland, United States
| | - Maria Oliva-Hemker
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Andrew Maslen
- Information Technology at Johns Hopkins Health System, Epic Project Leadership, Johns Hopkins Health System, Baltimore, Maryland, United States
| | - Harold P. Lehmann
- Division of Health Science Informatics, Johns Hopkins University, Baltimore, Maryland, United States
| | - Paul Nagy
- Department of Radiology, Johns Hopkins University School of Medicine, Johns Hopkins Technology Ventures, Baltimore, Maryland, United States
| | - Susan Hutfless
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, United States
| | - Ayse P. Gurses
- Information Technology at Johns Hopkins Health System, Epic Project Leadership, Johns Hopkins Health System, Baltimore, Maryland, United States
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Shear K, Rice H, Garabedian PM, Bjarnadottir R, Lathum N, Horgas AL, Harle CA, Dykes PC, Lucero R. Usability Testing of an Interoperable Computerized Clinical Decision Support Tool for Fall Risk Management in Primary Care. Appl Clin Inform 2023; 14:212-226. [PMID: 36599446 PMCID: PMC10017195 DOI: 10.1055/a-2006-4936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 01/02/2023] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Falls are a widespread and persistent problem for community-dwelling older adults. Use of fall prevention guidelines in the primary care setting has been suboptimal. Interoperable computerized clinical decision support systems have the potential to increase engagement with fall risk management at scale. To support fall risk management across organizations, our team developed the ASPIRE tool for use in differing primary care clinics using interoperable standards. OBJECTIVES Usability testing of ASPIRE was conducted to measure ease of access, overall usability, learnability, and acceptability prior to pilot . METHODS Participants were recruited using purposive sampling from two sites with different electronic health records and different clinical organizations. Formative testing rooted in user-centered design was followed by summative testing using a simulation approach. During summative testing participants used ASPIRE across two clinical scenarios and were randomized to determine which scenario they saw first. Single Ease Question and System Usability Scale were used in addition to analysis of recorded sessions in NVivo. RESULTS All 14 participants rated the usability of ASPIRE as above average based on usability benchmarks for the System Usability Scale metric. Time on task decreased significantly between the first and second scenarios indicating good learnability. However, acceptability data were more mixed with some recommendations being consistently accepted while others were adopted less frequently. CONCLUSION This study described the usability testing of the ASPIRE system within two different organizations using different electronic health records. Overall, the system was rated well, and further pilot testing should be done to validate that these positive results translate into clinical practice. Due to its interoperable design, ASPIRE could be integrated into diverse organizations allowing a tailored implementation without the need to build a new system for each organization. This distinction makes ASPIRE well positioned to impact the challenge of falls at scale.
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Affiliation(s)
- Kristen Shear
- Department of Family, Community, and Health Systems Science, College of Nursing, University of Florida, Gainesville, Florida, United States
| | - Hannah Rice
- Department of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Pamela M. Garabedian
- Department of Information Systems, Mass General Brigham, Somerville, Massachusetts, United States
| | - Ragnhildur Bjarnadottir
- Department of Family, Community, and Health Systems Science, College of Nursing, University of Florida, Gainesville, Florida, United States
| | - Nancy Lathum
- Department of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Ann L. Horgas
- Department of Biobehavioral Nursing Science, College of Nursing, University of Florida, Gainesville, Florida, United States
| | - Christopher A. Harle
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida, United States
| | - Patricia C. Dykes
- Department of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Robert Lucero
- UCLA School of Nursing, University of California Los Angeles, Los Angeles, California, United States
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