Macroergonomic factors in the patient work system: examining the context of patients with chronic illness

Caring for those who care: key challenges and improvement opportunities for health professionals working with children with disabilities

This paper investigates the challenges faced by health professionals working with children with disabilities, with the aim of identifying areas for improvement. Employing a focus group method, the study involved knowledge levelling, discussions, problematization, cause formulation, and validation. A diverse team of ten professionals participated, including physiotherapists, speech therapists, occupational therapists, psychologists, nursing technicians, and social workers. Findings reveal organisational inflexibility in appointment scheduling, lack of deadlines affecting case monitoring, and the mental strain of immediate clinical responses. Effective communication and multidisciplinary care emerge as beneficial. Proposed improvements include flexible space utilisation, enhanced room design, structured collaboration training, role clarification, parent partnerships, flexible scheduling, and continuous professional development. This study unveils unique challenges and rewards in the healthcare environment, offering insights into causative factors and practical strategies for enhancing the work of health professionals working with children with disabilities.

Macroergonomic components of the patient work system shaping dyadic care management during adolescence: a case study of type 1 diabetes

The role of the social, physical, and organisational environments in shaping how patients and their caregivers perform work remains largely unexplored in human factors/ergonomics literature. This study recruited 19 dyads consisting of a parent and their child with type 1 diabetes to be interviewed individually and analysed using a macroergonomic framework. Our findings aligned with the macroergonomic factors as presented in previous models, while highlighting the need to expand upon certain components to gain a more comprehensive representation of the patient work system as relevant to dyadic management. Examples of design efforts that should follow from these findings include expanding existing data sharing options to include information from the external environment and capitalising on the capabilities of artificial intelligence as a decision support system. Future research should focus on longitudinally assessing patient work systems throughout transition periods in addition to more explicitly exploring the roles of social network members.

Caregivers' Contributions to Heart Failure Self-care: An Updated Systematic Review

BACKGROUND

A previous systematic review reporting the contributions of informal, unpaid caregivers to patient heart failure (HF) self-care requires updating to better inform research, practice, and policy.

OBJECTIVE

The aim of this study was to provide an updated review answering the questions: (1) What specific activities do informal caregivers of adults with HF take part in related to HF self-care? (2) Have the activities that informal caregivers of adults with HF take part in related to HF self-care changed over time? (3) What are the gaps in the science?

METHODS

This review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, CINAHL, EMBASE, and Cochrane CENTRAL databases were searched. Eligible studies involved an informal, unpaid caregiver of an adult with HF as a study variable or participant. Caregiving activities were benchmarked using the theory of self-care in chronic illness.

RESULTS

Two thousand one hundred fifty-four research reports were identified, of which 64 met criteria. Caregivers' contributions occurred in self-care maintenance (91%), monitoring (54%), and management (46%). Activities performed directly on or to the patient were reported more frequently than activities performed for the patient. Change over time involved the 3 domains differentially. Gaps include ambiguous self-care activity descriptions, inadequate caregiving time quantification, and underrepresented self-care monitoring, supportive, and communication activities.

CONCLUSIONS

Newly identified caregiver-reported activities support updating the theory of self-care in chronic illness to include activities currently considered ancillary to HF self-care. Identified gaps highlight the need to define specific caregiving activities, determine task difficulty and burden, and identify caregiver self-care strategy and education needs. Exposing the hidden work of caregiving is essential to inform policy and practice.

High School Teachers' Experiences of Consumer Technologies for Stress Management During the COVID-19 Pandemic: Qualitative Study

BACKGROUND

Stress in education is an adverse reaction that teachers have to excessive pressures or other types of demands placed on them. Consumer digital technologies are already being used by teachers for stress management, albeit not in a systematic way. Understanding teachers' experiences and the long-term use of technologies to support stress self-management in the educational context is essential for meaningful insight into the value, opportunity, and benefits of use.

OBJECTIVE

The aim of this study was first to understand teachers' experiences of consumer technologies for stress management. They were chosen by teachers from a taxonomy tailored to their stress management. The second aim was to explore whether their experiences of use evolved over time as teachers transitioned from working at home during lockdown to working full time on school premises.

METHODS

A longitudinal study intended for 6 weeks in the summer term (2020) was extended because of COVID-19 into the autumn term, lasting up to 27 weeks. Teachers chose to use a Withings smartwatch or the Wysa, Daylio, or Teacher Tapp apps. In total, 2 semistructured interviews and web-based surveys were conducted with 8 teachers in South London in the summer term, and 6 (75%) of them took part in a third interview in the autumn term. The interviews were analyzed by creating case studies and conducting cross-case analysis.

RESULTS

The teachers described that the data captured or shared by the technology powerfully illustrated the physical and psychosocial toll of their work. This insight gave teachers permission to destress and self-care. The social-emotional confidence generated also led to empathy toward colleagues, and a virtuous cycle of knowledge, self-compassion, permission, and stress management action was demonstrated. Although the COVID-19 pandemic added a new source of stress, it also meant that teachers' stress management experiences could be contrasted between working from home and then back in school. More intentional self-care was demonstrated when back in school, sometimes without the need to refer to the data or technology.

CONCLUSIONS

The findings of this study demonstrate that taking a situated approach to understand the real-world, existential significance and value of data generates contextually informed insights. Where a strategic personal choice of consumer technology is enabled for high school heads of year, the data generated are perceived as holistic, with personal and professional salience, and are motivational in the educational context. Technology adoption was aided by the pandemic conditions of home working, and this flexibility would otherwise need workplace facilitation. These findings add to the value proposition of technologies for individual stress management and workforce health outcomes pertinent to educators, policy makers, and designers.

Designing mobile health to align with the social determinants of health

The maternal health crisis in the United States is becoming increasingly worse, with disparities continuing to escalate among marginalized populations. mHealth can contribute to addressing the Social Determinants of Health (SDOH) that produce inequities in maternal morbidity and mortality. Reducing inequities through mHealth can be achieved by designing these technologies to align with SDOH. As mHealth developed to support maternal health has primarily supported the extension of clinical care, there is an opportunity to integrate frameworks and methods from human factors/ergonomics and public health to produce thorough comprehension of SDOH through intentional partnerships with marginalized populations. Potential for this opportunity is presented through a case study derived from a community-based participatory research process focused on transportation access to maternal health services. Through multi-faceted, interdisciplinary, and community-based approaches to designing mHealth that attends to the systemic factors that generate and escalate inequities, improvements in the maternal health crisis could be realized.

"There Is Method to This Madness" A Qualitative Investigation of Home Medication Management by Older Adults

OBJECTIVES

This paper explores (1) the systems and processes older adults use to manage medications at home, and (2) the well-being goals of personal interest that motivate them.

METHODS

Qualitative interviews were conducted in the homes of 12 older adults in a small city in the Midwest United States. Interviews were analyzed using inductive template analysis.

RESULTS

The average age of older adults in this study was 74.2 years (SD = 10.5), 66.7% were women. The most prominent home medication management tools used were pill boxes, containers and vials, and medication lists. Routines were often aligned with activities of daily living such as teeth brushing and eating. Their medication management work occurred in contexts of other household members and budget constraints. Routines and practices were sometimes idiosyncratic adaptations and supported goals of maintaining control and decreasing vulnerability.

CONCLUSION

In developing routines for home medication management, older adults developed systems and deliberate processes to make sense of their medication experiences in the context of their home environment and based on available resources.

What makes a home? Designing home personas to represent the homes of families caring for children with medical complexity

Personas are widely recognized as valuable design tools for communicating dimensions of individuals, yet they often lack critical contextual factors. For those people managing chronic health conditions, the home is a critical context of their patient work system (PWS). We propose the development of 'home personas' to convey essential aspects of the home context to those tasked with designing technologies and interventions to fit it. We used an iterative, multi-stakeholder design process to design 'home personas' for a model population, families caring for children with medical complexity. Each of the four resultant home personas-Multi-level, Customized, Ranch, and Rental-has a unique home layout, pain points, and are described on three dimensions that emerged from the data. This study builds on a foundation of work in the emerging field of Patient Ergonomics, describing a mechanism for distilling rich descriptions of the PWS into brief yet informative design tools.

Quantifying the qualitative: exploring epistemic network analysis as a method to study work system interactions

Studying interactions faces methodological challenges and existing methods, such as configural diagramming, have limitations. This work demonstrates Epistemic Network Analysis (ENA) as an analytical method to construct configural diagrams. We demonstrated ENA as an analytical tool by applying this method to study dementia caregiver work systems. We conducted 20 semi-structured interviews with caregivers to collect caregiving experiences. Guided by the Patient Work System model, we conducted a directed content analysis to identify work system components and used ENA to study interactions between components. By using ENA to create configural diagrams, we identified five frequently occurring interactions, compared work system configurations of caregivers providing care at home and away from home. Although we were underpowered to determine statistically significant differences, we identified visual and qualitative differences. Our results demonstrate the capability of ENA as an analytical method for studying work system interactions through configural diagramming. Practitioner summary: A new methodology, Epistemic Network Analysis (ENA), was presented to better support the study of work system interactions through configural diagramming. ENA was applied to qualitative data to demonstrate the capabilities of this method to construct configural diagrams of the work system. This study successfully demonstrated that ENA can visually represent and describe work system configurations.

Digital health and modern technologies applied in patients with heart failure: Can we support patients’ psychosocial well-being?

Despite advances in the treatment of heart failure (HF), the physical symptoms and stress of the disease continue to negatively impact patients’ health outcomes. Technology now offers promising ways to integrate personalized support from health care professionals via a variety of platforms. Digital health technology solutions using mobile devices or those that allow remote patient monitoring are potentially more cost effective and may replace in-person interaction. Notably, digital health methods may not only improve clinical outcomes but may also improve the psycho-social status of HF patients. Using digital health to address biopsychosocial variables, including elements of the person and their context is valuable when considering chronic illness and HF in particular, given the multiple, cross-level factors affecting chronic illness clinical management needed for HF self-care.

Professional Organizers’ Description of Personal Health Information Management Work with a Spotlight on the Practices of Older Adults: A Qualitative e-Delphi Study (Preprint)

BACKGROUND

Personal health information (PHI) is created on behalf of and by health care consumers to support their care and wellness. Available tools designed to support PHI management (PHIM) remain insufficient. A comprehensive understanding of PHIM work is required, particularly for older adults, to offer more effective PHIM tools and support.

OBJECTIVE

The primary objective of this study was to use the Patient Work System model to provide a holistic description of PHIM work from the perspective of professional organizers with experience assisting health care consumers, including older adults, in managing their PHI. A secondary objective was to examine how factors associated with 4 Patient Work System components (person, tasks, tools and technologies, and context) interact to support or compromise PHIM work performance.

METHODS

A modified e-Delphi methodology was used to complete 3 web-based rounds of open-ended questions and obtain consensus among a panel of 16 experts in professional organizing. Data were collected between April and December 2017. The Patient Work System model was used as a coding schema and guided the interpretation of findings during the analysis.

RESULTS

The PHIM work of adults who sought assistance focused on the tasks of acquiring, organizing, and storing 3 classifications of PHI (medical, financial, and reference) and then processing, reconciling, and storing the medical and financial classifications to tend to their health, health care, and health finances. We also found that the complexities of PHI and PHIM-related work often exceeded the abilities and willingness of those who sought assistance. A total of 6 factors contributed to the complexity of PHIM work. The misalignment of these factors was found to increase the PHIM workload, particularly for older adults. The life changes that often accompanied aging, coupled with obscure and fragmented health care provider- and insurer-generated PHI, created the need for much PHIM work. Acquiring and integrating obscure and fragmented PHI, detecting and reconciling PHI discrepancies, and protecting PHI held by health care consumers were among the most burdensome tasks, especially for older adults. Consequently, personal stakeholders (paid and unpaid) were called upon or voluntarily stepped in to assist with PHIM work.

CONCLUSIONS

Streamlining and automating 2 of the most common and burdensome PHIM undertakings could drastically reduce health care consumers' PHIM workload: developing and maintaining accurate current and past health summaries and tracking medical bills and insurance claims to reconcile discrepancies. Other improvements that hold promise are the simplification and standardization of commonly used financial and medical PHI; standardization and automation of commonly used PHI acquisition interfaces; and provision of secure, Health Insurance Portability and Accountability Act (HIPAA)-certified PHI tools and technologies that control multiperson access for PHI stored by health care consumers in electronic and paper formats.

Patient Work Personas of Type 2 Diabetes—A Data-Driven Approach to Persona Development and Validation

Introduction

Many have argued that a “one-size-fits-all” approach to designing digital health is not optimal and that personalisation is essential to achieve targeted outcomes. Yet, most digital health practitioners struggle to identify which design aspect require personalisation. Personas are commonly used to communicate patient needs in consumer-oriented digital health design, however there is often a lack of reproducible clarity on development process and few attempts to assess their accuracy against the targeted population. In this study, we present a transparent approach to designing and validating personas, as well as identifying aspects of “patient work,” defined as the combined total of work tasks required to manage one's health and the contextual factors influencing such tasks, that are sensitive to an individual's context and may require personalisation.

Methods

A data-driven approach was used to develop and validate personas for people with Type 2 diabetes mellitus (T2DM), focusing on patient work. Eight different personas of T2DM patient work were constructed based physical activity, dietary control and contextual influences of 26 elderly Australian participants (median age = 72 years) via wearable camera footage, interviews, and self-reported diaries. These personas were validated for accuracy and perceived usefulness for design, both by the original participants and a younger (median age bracket = 45–54 years) independent online cohort f 131 T2DM patients from the United Kingdom and the United States.

Results

Both the original participants and the independent online cohort reported the personas to be accurate representations of their patient work routines. For the independent online cohort, 74% (97/131) indicated personas stratified to their levels of exercise and diet control were similar to their patient work routines. Findings from both cohorts highlight aspects that may require personalisation include daily routine, use of time, and social context.

Conclusion

Personas made for a specific purpose can be very accurate if developed from real-life data. Our personas retained their accuracy even when tested against an independent cohort, demonstrating their generalisability. Our data-driven approach clarified the often non-transparent process of persona development and validation, suggesting it is possible to systematically identify whether persona components are accurate or. and which aspects require more personalisation and tailoring.

Exploring how caregivers for people living with dementia use strategies to overcome work system constraints

Informal caregivers for persons living with dementia (PLWD) require interventions that incorporate caregiving context. We used the Patient Work System model to characterize caregiving context by identifying work system constraints experienced by caregivers during dementia care events (e.g., managing behavioral symptoms of dementia) and strategies used to overcome constraints. We conducted twenty semi-structured interviews with caregivers. We performed upward abstraction and strategy mapping and identified seven work system constraints and eight strategies used to overcome constraints across three care events. We found that strategies used by caregivers either directly modified a constraint or emphasized other positive work system components to overcome a constraint. For example a caregiver modified their bathroom to support the PLWD in bathing themselves properly and safely. These findings provide an understanding of how real-world context influences how caregivers deliver dementia care and the design and implementation of systems that support dementia caregivers.

Older adults' personal health information management: The role and perspective of various healthcare providers

The management of personal health information (PHI) by older adults (OAs) takes place within a socio-technical context and requires the support of various stakeholders, including healthcare providers. This study investigates provider roles in supporting OA personal health information management (PHIM), barriers they face, and related design implications for health information technology (HIT). We interviewed 27 providers serving OAs in Seattle, WA. Providers support OA PHIM through medication management, interpreting HI, and providing resources. Barriers to OA PHIM described by providers include (1) challenges with communication between OAs, providers, and caregivers, (2) limited time and resources, and (3) limitations of tools such as secure messaging. Considering these barriers, provider roles, and the socio-technical context for HIT implementation, we recommend the design of HIT that facilitates communication across multiple provider types, integrates caregivers and patient-generated data, supports understanding of OA home environments, and offers credible health resources designed for OAs.

"It's a mess sometimes": patient perspectives on provider responses to healthcare costs, and how informatics interventions can help support cost-sensitive care decisions

OBJECTIVE

We investigated patient experiences with medication- and test-related cost conversations with healthcare providers to identify their preferences for future informatics tools to facilitate cost-sensitive care decisions.

MATERIALS AND METHODS

We conducted 18 semistructured interviews with diverse patients (ages 24-81) in a Midwestern health system in the United States. We identified themes through 2 rounds of qualitative coding.

RESULTS

Patients believed their providers could help reduce medication-related costs but did not see how providers could influence test-related costs. Patients viewed cost conversations about medications as beneficial when providers could adjust medical recommendations or provide resources. However, cost conversations did not always occur when patients felt they were needed. Consequently, patients faced a "cascade of work" to address affordability challenges. To prevent this, collaborative informatics tools could facilitate cost conversations and shared decision-making by providing information about a patient's financial constraints, enabling comparisons of medication/testing options, and addressing transportation logistics to facilitate patient follow-through.

DISCUSSION

Like providers, patients want informatics tools that address patient out-of-pocket costs. They want to discuss healthcare costs to reduce the frequency of unaffordable costs and obtain proactive assistance. Informatics interventions could minimize the cascade of patient work through shared decision-making and preventative actions. Such tools might integrate information about efficacy, costs, and side effects to support decisions, present patient decision aids, facilitate coordination among healthcare units, and eventually improve patient outcomes.

CONCLUSION

To prevent a burdensome cascade of work for patients, informatics tools could be designed to support cost conversations and decisions between patients and providers.

Human factors and ergonomics methods for pharmacy research and clinical practice

BACKGROUND

Human factors and ergonomics (HFE) is a scientific and practical human-centered discipline that studies and improves human performance in sociotechnical systems. HFE in pharmacy promotes the human-centered design of systems to support individuals and teams performing medication-related work.

OBJECTIVE

To review select HFE methods well suited to address pharmacy challenges, with examples of their application in pharmacy.

METHODS

We define the scope of HFE methods in pharmacy as applications to pharmacy settings, such as inpatient or community pharmacies, as well as medication-related phenomena such as medication safety, adherence, or deprescribing. We identify and present seven categories of HFE methods suited to widespread use for pharmacy research and clinical practice.

RESULTS

Categories of HFE methods applicable to pharmacy include work system analysis; task analysis; workload assessment; medication safety and error analysis; user-centered and participatory design; usability evaluation; and physical ergonomics. HFE methods are used in three broad phases of human-centered design and evaluation: study; design; and evaluation. The most robust applications of HFE methods involve the combination of HFE methods across all three phases. Two cases illustrate such a comprehensive application of HFE: one case of medication package, label, and information design and a second case of human-centered design of a digital decision aid for medication safety.

CONCLUSIONS

Pharmacy, including the places where pharmacy professionals work and the multistep process of medication use across people and settings, can benefit from HFE. This is because pharmacy is a human-centered sociotechnical system with an existing tradition of studying and analyzing the present state, designing solutions to problems, and evaluating those solutions in laboratory or practice settings. We conclude by addressing common concerns about the implementation of HFE methods and urge the adoption of HFE methods in pharmacy.

A macroergonomics perspective for exploring safety culture factors: a qualitative content analysis approach

Objective. Although assessing safety culture is a useful approach in reducing occupational accidents, there are no qualitative examinations of it based on a systems approach. This study was conducted with the aim of explaining the experiences of gas refinement personnel on safety issues and extending safety culture constructs using a macroergonomics approach. Methods. A directed qualitative content analysis was used. Data were collected by 18 semi-structured interviews based on a work subsystems model as a guiding framework. Results. From the interviews, 420 codes were extracted. By placing codes into subsystems, five categories in the organization subsystem, two categories in the job subsystem, one category in the human subsystem, two categories in the technology subsystem and two categories in the environment subsystem emerged. In addition to the common factors in assessment scales, factors such as work schedule, safety standards in new technologies and external factors of the organization like financial conditions were considered effective for workers' attitudes and safety behaviors. Conclusion. Investigating personnel perspectives about safety in the workplace based on a macroergonomics approach developed distinct factors in safety culture. It seems that industry features, environment and technology along with organizational factors are important in assessing safety culture.

A Qualitative Study of the Social and Lived Experiences of Homebound Older Adults

OBJECTIVE

The number of homebound older adults is increasing in the United States. We aimed to examine their social and lived experiences and to understand their perspectives on their situation, feelings, and coping mechanisms.

METHODS

We conducted a cross-sectional qualitative study using semi-structured interviews with 18 older homebound individuals in Central Virginia.

RESULTS

Homebound older adults experienced both physical and mental health challenges that restricted their ability to participate in activities of daily living, recreation, and social interactions. Participants often felt dependent, helpless, lonely, and socially isolated. Those who communicated regularly with friends, family, and health care providers reported positive benefits from these interactions.

DISCUSSION

Participants faced challenges to their physical, emotional, and mental well-being. Our findings might help clinicians, policymakers, and community organizations understand how to better support homebound older adults. We should provide educational opportunities, respect their autonomy, and implement initiatives to address their isolation and loneliness.

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.

How Patient Work Changes Over Time for People With Multimorbid Type 2 Diabetes: Qualitative Study

Background

The experiences of patients change throughout their illness trajectory and differ according to their medical history, but digital support tools are often designed for one specific moment in time and do not change with the patient as their health state changes. This presents a fragmented support pattern where patients have to move from one app to another as they move between health states, and some subpopulations of patients do not have their needs addressed at all.

Objective

This study aims to investigate how patient work evolves over time for those living with type 2 diabetes mellitus and chronic multimorbidity, and explore the implications for digital support system design.

Methods

In total, 26 patients with type 2 diabetes mellitus and chronic multimorbidity were recruited. Each interview was conducted twice, and interviews were transcribed and analyzed according to the Chronic Illness Trajectory Model.

Results

Four unique illness trajectories were identified with different patient work goals and needs: living with stable chronic conditions involves patients seeking to make patient work as routinized and invisible as possible; dealing with cycles of acute or crisis episodes included heavily multimorbid patients who sought support with therapy adherence; responding to unstable changes described patients currently experiencing rapid health changes and increasing patient work intensity; and coming back from crisis focused on patients coping with a loss of normalcy.

Conclusions

Patient work changes over time based on the experiences of the individual, and its timing and trajectory need to be considered when designing digital support interventions.

International Registered Report Identifier (IRRID)

RR2-10.1136/bmjopen-2018-022163

Patients Are Knowledge Workers in the Clinical Information Space

BACKGROUND

Limited research exists on patient knowledge/cognition or "getting inside patients' heads." Because patients possess unique and privileged knowledge, clinicians need this information to make patient-centered and coordinated treatment planning decisions. To achieve patient-centered care, we characterize patient knowledge and contributions to the clinical information space.

METHODS AND OBJECTIVES

In a theoretical overview, we explore the relevance of patient knowledge to care provision, apply historical perspectives of knowledge acquisition to patient knowledge, propose a representation of patient knowledge types across the continuum of care, and include illustrative vignettes about Mr. Jones. We highlight how the field of human factors (a core competency of health informatics) provides a perspective and methods for eliciting and characterizing patient knowledge.

CONCLUSION

Patients play a vital role in the clinical information space by possessing and sharing unique knowledge relevant to the clinical picture. Without a patient's contributions, the clinical picture of the patient is incomplete. A human factors perspective informs patient-centered care and health information technology solutions to support clinical information sharing.

Understanding the experiences of self-injurious behavior in autism spectrum disorder: Implications for monitoring technology design

OBJECTIVE

Monitoring technology may assist in managing self-injurious behavior (SIB), a pervasive concern in autism spectrum disorder (ASD). Affiliated stakeholder perspectives should be considered to design effective and accepted SIB monitoring methods. We examined caregiver experiences to generate design guidance for SIB monitoring technology.

MATERIALS AND METHODS

Twenty-three educators and 16 parents of individuals with ASD and SIB completed interviews or focus groups to discuss needs related to monitoring SIB and associated technology use.

RESULTS

Qualitative content analysis of participant responses revealed 7 main themes associated with SIB and technology: triggers, emotional responses, SIB characteristics, management approaches, caregiver impact, child/student impact, and sensory/technology preferences.

DISCUSSION

The derived themes indicated areas of emphasis for design at the intersection of monitoring and SIB. Systems design at this intersection should consider the range of manifestations of and management approaches for SIB. It should also attend to interactions among children with SIB, their caregivers, and the technology. Design should prioritize the transferability of physical technology and behavioral data as well as the safety, durability, and sensory implications of technology.

CONCLUSIONS

The collected stakeholder perspectives provide preliminary groundwork for an SIB monitoring system responsive to needs as articulated by caregivers. Technology design based on this groundwork should follow an iterative process that meaningfully engages caregivers and individuals with SIB in naturalistic settings.

Human factors/ergonomics work system analysis of patient work: state of the science and future directions

PURPOSE

To demonstrate the use and value of the Human Factors/Ergonomics-based Systems Engineering Initiative for Patient Safety (SEIPS) family of work system models for studying and improving patient work.

DATA SOURCES

We conducted a review of the published empirical literature applying the SEIPS family of work system models for patient work.

STUDY SELECTION

Included studies had to apply one of the SEIPS family of work system models to study patient work; be published in a peer-reviewed journal in English and include analysis of data. We identified 16 articles that met our inclusion criteria.

DATA EXTRACTION

For each study, we extracted settings and situations in which models were applied; research design; study methods; model(s) used; type and number of study participants; study objective(s); whether the study included an intervention; specific aspects of the model used; knowledge generated about patient work and benefits of using the models.

RESULTS OF DATA SYNTHESIS

Our analysis revealed that a majority of studies were conducted in the United States, used qualitative or mixed methods and employed a variety of data collection techniques to study adult patient populations with chronic illness and their informal caregivers and healthcare providers performing patient work in the home and clinical setting. The studies resulted in a variety of useful products, demonstrating several benefits of using the models.

CONCLUSION

Our review has demonstrated the value of using the SEIPS family of work systems models to study and improve patient and family contributions to health-related work.

Medication transitions: Vulnerable periods of change in need of human factors and ergonomics

We present a novel view of transitions from the lens of patient ergonomics (the "science of patient work"), which posits that patients and other non-professionals perform effortful work towards health-related goals. In patient work transitions, patients experience changes in, for example, health, task demands, work capacity, roles and responsibilities, knowledge and skills, routines, needs and technologies. Medication transitions are a particularly vulnerable type of patient work transitions. We describe two cases of medication transitions-new medications and medication deprescribing-in which the patient work lens reveals many accompanying changes, vulnerabilities, and opportunities for human factors and ergonomics.

A Simplified System Usability Scale (SUS) for Cognitively Impaired and Older Adults

We present the 10-item Simplified System Usability Scale (SUS) for Cognitively Impaired and Older Adults, which we have used in several studies since 2016. The Simplified SUS is a revised version of the SUS, a brief, psychometrically valid, and widely used global measure of usability. To improve the ease of administration, the Simplified SUS rewords 9 of 10 SUS items and replaces the original SUS question about inconsistency with a question about confusion. The Simplified SUS retains the SUS's 10-item design, five-item agreement-based Likert scale, and alternating valence of positively worded odd items and negatively worded even items. Because of this, the Simplified SUS can be interpreted the same way as the traditional SUS. The Simplified SUS is an example of an off-the-shelf human factors method adapted for work with vulnerable populations and usable by practitioners or researchers without human factors training.

Patient decision-making personas: An application of a patient-centered cognitive task analysis (P-CTA)

Personas can be used to understand patterns of variation in patients' performance of cognitive work, particularly self-care decision making. In this study, we used a patient-centered cognitive task analysis (P-CTA) to develop self-care decision-making personas. We collected data from 24 older adults with chronic heart failure and 14 support persons, using critical incident and fictitious scenario interviews. Qualitative analyses produced three personas but revealed that individuals exemplify different personas across situations. The Rule-Following persona seeks clear rules, exercises caution under uncertainty, and grounds actions in confidence in clinician experts. The Researching persona seeks information to gain better understanding, invents strategies, and conducts experiments independently or with clinicians. The Disengaging persona does not actively seek rules or information and does not attempt to reduce uncertainty or conduct experiments. We discuss the situational nature of personas, their use in design, and the benefits of P-CTA for studying patient decision making.

A qualitative study of health-care experiences and challenges faced by ageing homebound adults

BACKGROUND

The ageing of the global population is associated with an increasing prevalence of chronic diseases and functional impairments, resulting in a greater proportion of homebound individuals.

OBJECTIVE

To examine the health-care experiences of older homebound adults who have not previously received home-based primary care (HBPC). To explore their impressions of this method of care.

DESIGN

Cross-sectional qualitative study using semi-structured interviews.

SETTING AND PARTICIPANTS

18 older homebound individuals in Central Virginia.

RESULTS

Our findings revealed that homebound individuals faced significant health challenges, including pain resulting from various comorbidities. They felt that their mobility was restricted by their physical conditions and transportation challenges. These were major barriers to social outings and health-care access. Participants left their homes infrequently and typically with assistance. Regarding office-based care, participants were concerned about long wait times and making timely appointments. Some thought that HBPC would be convenient and could result in better quality care; however, others believed that the structure of the health-care system and its focus on efficiency would not permit routine HBPC.

DISCUSSION AND CONCLUSIONS

Older homebound adults in this study faced high burdens of disease, a lack of mobility and difficulty accessing quality health care. Our observations may help researchers and clinicians better understand the health-care experiences and personal opinions of older homebound individuals, informing the development of effective and empathetic home-based care. Participant responses illuminated a need for education about HBPC. We must improve health-care delivery and develop comprehensive, patient-centered HBPC to meet the needs of homebound individuals.

Patient Work and Their Contexts: Scoping Review

Background

Having patients self-manage their health conditions is a widely promoted concept, but many patients struggle to practice it effectively. Moreover, few studies have analyzed the nature of work required from patients and how such work fits into the context of their daily life.

Objective

This study aimed to review the characteristics of patient work in adult patients. Patient work refers to tasks that health conditions impose on patients (eg, taking medications) within a system of contextual factors.

Methods

A systematic scoping review was conducted using narrative synthesis. Data were extracted from PubMed, Excerpta Medica database (EMBASE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), and PsycINFO, including studies from August 2013 to August 2018. The included studies focused on adult patients and assessed one or more of the following: (1) physical health–related tasks, (2) cognitive health–related tasks, or (3) contextual factors affecting these tasks. Tasks were categorized according to the themes that emerged: (1) if the task is always visible to others or can be cognitive, (2) if the task must be conducted collaboratively or can be conducted alone, and (3) if the task was done with the purpose of creating resources. Contextual factors were grouped according to the level at which they exert influence (micro, meso, or macro) and where they fit in the patient work system (the macroergonomic layer of physical, social, and organizational factors; the mesoergonomic layer of household and community; and the microergonomic triad of person-task-tools).

Results

In total, 67 publications were included, with 58 original research articles and 9 review articles. A variety of patient work tasks were observed, ranging from physical and tangible tasks (such as taking medications and visiting health care professionals) to psychological and social tasks (such as creating coping strategies). Patient work was affected by a range of contextual factors on the micro, meso, or macro levels. Our results indicate that most patient work was done alone, in private, and often imposing cognitive burden with low amounts of support.

Conclusions

This review sought to provide insight into the work burden of health management from a patient perspective and how patient context influences such work. For many patients, health-related work is ever present, invisible, and overwhelming. When researchers and clinicians design and implement patient-facing interventions, it is important to understand how the extra work impacts one’s internal state and coping strategy, how such work fits into daily routines, and if these changes could be maintained in the long term.

SEIPS 3.0: Human-centered design of the patient journey for patient safety

The Systems Engineering Initiative for Patient Safety (SEIPS) and SEIPS 2.0 models provide a framework for integrating Human Factors and Ergonomics (HFE) in health care quality and patient safety improvement. As care becomes increasingly distributed over space and time, the "process" component of the SEIPS model needs to evolve and represent this additional complexity. In this paper, we review different ways that the process component of the SEIPS models have been described and applied. We then propose the SEIPS 3.0 model, which expands the process component, using the concept of the patient journey to describe the spatio-temporal distribution of patients' interactions with multiple care settings over time. This new SEIPS 3.0 sociotechnical systems approach to the patient journey and patient safety poses several conceptual and methodological challenges to HFE researchers and professionals, including the need to consider multiple perspectives, issues with genuine participation, and HFE work at the boundaries.

Self-Management Characterization for Families of Children With Medical Complexity and Their Social Networks: Protocol for a Qualitative Assessment

Background

Children with medical complexity (CMC) present rewarding but complex challenges for the health care system. Transforming high-quality care practices for this population requires multiple stakeholders and development of innovative models of care. Importantly, care coordination requires significant self-management by families in home- and community-based settings. Self-management often requires that families of CMC rely on vast and diverse social networks, encompassing both online and offline social relationships with individuals and groups. The result is a support network surrounding the family to help accomplish self-management of medical tasks and care coordination.

Objective

The goal of this study is to use a theoretically driven perspective to systematically elucidate the range of self-management experiences across families of CMC embedded in diverse social networks and contextual environments. This approach will allow for characterization of the structure and process of self-management of CMC with respect to social networks, both in person and digitally. This research proposal aims to address the significant gaps in the self-management literature surrounding CMC, including the following: (1) how self-management responsibilities are distributed and negotiated among the social network and (2) how individual-, family-, and system-level factors influence self-management approaches for CMC from a theoretically driven perspective.

Methods

This study will encompass a qualitative descriptive approach to understand self-management practices among CMC and their social networks. Data collection and analysis will be guided by a theoretical and methodological framework, which synthesizes perspectives from nursing, human factors engineering, public health, and family counseling. Data collection will consist of semistructured interviews with children, parents, and social network members, inclusive of individuals such as friends, neighbors, and community members, as well as online communities and individuals. Data analysis will consist of a combination of inductive and deductive methods of qualitative content analysis, which will be analyzed at both individual and multiadic levels, where interview data from two or more individuals, focused on the same experience, will be comparatively analyzed.

Results

This study will take approximately 18 months to complete. Our long-term goals are to translate the qualitative analysis into (1) health IT design guidance for innovative approaches to self-management and (2) direct policy guidance for families of CMC enrolled in Medicaid and private insurance.

Conclusions

Multiple innovative components of this study will enable us to gain a comprehensive and nuanced understanding of the lived experience of self-management of CMC. In particular, by synthesizing and applying theoretical and methodological approaches from multiple disciplines, we plan to create novel informatics and policy solutions to support their care within home and community settings.

International Registered Report Identifier (IRRID)

PRR1-10.2196/14810

A Sociotechnical Systems Approach Toward Tailored Design for Personal Health Information Management

We used a sociotechnical systems approach-which conceptualizes a system of interacting people, technologies, and tasks, to identify individual differences in personal health information management (PHIM) that can inform the design for patient-friendly environments, tools and technologies. We conducted a secondary thematic analysis of data collected as part of a parent project, vizHOME. The goal of vizHOME was to improve health and health outcomes through identifying key features in the environment that will inform the design of consumer health information technology HIT. We analyzed interview data collected from 20 individuals with diabetes. We found seven dimensions of PHIM: (1) level of privacy preferred for PHIM; (2) amount of engagement in PHIM; (3) extent of guidance preferred for PHIM; (4) level of documentation preferred for PHIM; (5) degree of physical distribution of PHIM; (6) amount of flexibility in PHIM routine; and (7) use of external cues to manage PHIM. Our results suggest that each dimension exists as a continuum, which are anchored from low to high. Exploring the interaction between PHIM and the sociotechnical system in which PHIM is performed revealed key dimensions of PHIM as well as individual differences in those PHIM dimensions. Identification of individual differences in PHIM can support the creation of human-centered design considerations for tailored environments, products, processes, and technologies that support PHIM. Future research will seek to validate PHIM dimensions in a larger population and develop a PHIM-typing measure to identify PHIM types toward tailoring processes, products, and to individual needs in context.

The desktop, or the top of the desk? The relative usefulness of household features for personal health information management

Sixty percent of the US population manages at least one chronic illness. For these patients, personal health information management (PHIM) is an integral part of daily life, and largely occurs within the home. However, the way in which the home supports PHIM has not been systematically investigated. The present study examined how members of the diabetic population use features of the home environment to support PHIM. Participants (N = 60) explored a simulated home environment, the VR CAVE, and identified the most useful features for performing three examples of PHIM tasks. The computer was perceived as the most useful feature for PHIM. However, perceived usefulness of features varied based on the PHIM task performed and the rooms in which features appeared. We conclude that a detailed study of the affordances of features is necessary to ease the burden of managing chronic illness, particularly diabetes mellitus, in the sociotechnical system of the home.

The role of human factors in neonatal patient safety

The relationship between the fields of human factors and patient safety is relatively nascent but represents a powerful interaction that has developed in only the last twenty years. Application of human factors principles, techniques, and science can facilitate the development of healthcare systems, protocols, and technology that leverage the enormous and adaptable capacity of human performance while acknowledging human vulnerability and decreasing the risk of error during patient care. This chapter will review these concepts and employ case studies from neonatal care to demonstrate how an understanding of human factors can be applied to improve patient safety.

Work systems analysis of sterile processing: decontamination

BACKGROUND

Few studies have explored the work of sterile processing departments (SPD) from a systems perspective. Effective decontamination is critical for removing organic matter and reducing microbial levels from used surgical instruments prior to disinfection or sterilisation and is delivered through a combination of human work and supporting technologies and processes.

OBJECTIVE

In this paper we report the results of a work systems analysis that sought to identify the complex multilevel interdependencies that create performance variation in decontamination and identify potential improvement interventions.

METHODS

The research was conducted at a 700-bed academic hospital with two reprocessing facilities decontaminating approximately 23 000 units each month. Mixed methods, including 56 hours of observations of work as done, formal and informal interviews with relevant stakeholders and analysis of data collected about the system, were used to iteratively develop a process map, task analysis, abstraction hierarchy and a variance matrix.

RESULTS

We identified 21 different performance shaping factors, 30 potential failures, 16 types of process variance, and 10 outcome variances in decontamination. Approximately 2% of trays were returned to decontamination from assembly, while decontamination problems were found in about 1% of surgical cases. Staff knowledge, production pressures, instrument design, tray composition and workstation design contributed to outcomes such as reduced throughput, tray defects, staff injuries, increased inventory and equipment costs, and patient injuries.

CONCLUSIONS

Ensuring patients and technicians' safety and efficient SPD operation requires improved design of instruments and the decontamination area, skilled staff, proper equipment maintenance and effective coordination of reprocessing tasks.

Performance-Shaping Factors Affecting Older Adults' Hospital-to-Home Transition Success: A Systems Approach

BACKGROUND AND OBJECTIVES

Facilitating older adults' successful hospital-to-home transitions remains a persistent challenge. To address this challenge, we applied a systems lens to identify and understand the performance-shaping factors (PSFs) related older adults' hospital-to-home transition success.

RESEARCH DESIGN AND METHODS

This study was a secondary analysis of semi-structured interviews from older adults (N = 31) recently discharged from a hospital and their informal caregivers (N = 13). We used a Human Factors Engineering approach to guide qualitative thematic analysis to develop four themes concerning the system conditions shaping hospital-to-home transition success.

RESULTS

The four themes concerning PSFs were: (a) the hospital-to-home transition was a complex multiphase process-the process unfolded over several months and required substantial, persistent investment/effort; (b) there were unmet needs for specialized tools-information and resources provided at hospital discharge were not aligned with requirements for transition success; (c) alignment of self-care routines with transition needs-pre-hospitalization routines could be supportive/disruptive and could deteriorate/be re-established; and (d) changing levels of work demand and capacity during the transition-demand often exceeded capacity leading to work overload.

DISCUSSION AND IMPLICATIONS

Our findings highlight that the transition is not an episodic event, but rather a longitudinal process extending beyond the days just after hospital discharge. Transition interventions to improve older adults' hospital-to-home transitions need to account for this complex multiphase process. Future interventions must be developed to support older adults and informal caregivers in navigating the establishment and re-establishment of routines and managing work demands and capacity during the transition process.

Performance-Shaping Factors Affecting Older Adults' Hospital-to-Home Transition Success: A Systems Approach

BACKGROUND AND OBJECTIVES

Facilitating older adults' successful hospital-to-home transitions remains a persistent challenge. To address this challenge, we applied a systems lens to identify and understand the performance-shaping factors (PSFs) related older adults' hospital-to-home transition success.

RESEARCH DESIGN AND METHODS

This study was a secondary analysis of semi-structured interviews from older adults (N = 31) recently discharged from a hospital and their informal caregivers (N = 13). We used a Human Factors Engineering approach to guide qualitative thematic analysis to develop four themes concerning the system conditions shaping hospital-to-home transition success.

RESULTS

The four themes concerning PSFs were: (a) the hospital-to-home transition was a complex multiphase process-the process unfolded over several months and required substantial, persistent investment/effort; (b) there were unmet needs for specialized tools-information and resources provided at hospital discharge were not aligned with requirements for transition success; (c) alignment of self-care routines with transition needs-pre-hospitalization routines could be supportive/disruptive and could deteriorate/be re-established; and (d) changing levels of work demand and capacity during the transition-demand often exceeded capacity leading to work overload.

DISCUSSION AND IMPLICATIONS

Our findings highlight that the transition is not an episodic event, but rather a longitudinal process extending beyond the days just after hospital discharge. Transition interventions to improve older adults' hospital-to-home transitions need to account for this complex multiphase process. Future interventions must be developed to support older adults and informal caregivers in navigating the establishment and re-establishment of routines and managing work demands and capacity during the transition process.

Engineering a Foundation for Partnership to Improve Medication Safety during Care Transitions

There are major gaps and barriers for patients and caregivers after hospital discharge to achieve safe medication use. Patients and caregivers are often not ready to take on the responsibility for medication management when transitioned from inpatient care. Current approaches tend to focus on adding isolated strategies. A system thinking can enable a fundamental transformation to redesign professionals' interactions with patients and caregivers with an explicit goal to develop patients and caregivers into true partners, with targeted roles, skills, attitude, knowledge, and tool support. We must recognize the fact that medication safety during care transition and, more so, at patient homes is the property of a "work system", in which the patient and caregivers are at the center, with collaboration with health professionals. Innovative ideas are needed to engineer work system components by systematically examining professionals' interactions with patients and caregivers, such as those during hospital stays and transitions (e.g., follow-up phone calls, community pharmacist consults, and home visits). Based on human factors principles, we describe a set of recommendations on engineering partnership with patients and their caregivers at different stages of a care episode, to enable productive interactions among work systems that are distributed and are often limited in their ability to exchange information and co-align their interests.

Patient work from a context and time use perspective: a mixed-methods study protocol

INTRODUCTION

Self-management is widely promoted but less attention is focused on the work required from patients. To date, many individuals struggle to practise self-management. 'Patient work', a concept that examines the 'work' involved in self-management, is an approach to understanding the tasks, effort, time and context from patient perspective. The purpose of our study is to use a novel approach combining non-obstructive observations via digital devices with in-depth qualitative data about health behaviours and motivations, to capture the full range of patient work experienced by people with type 2 diabetes and chronic comorbidities. It aims to yield comprehensive insights about 'what works' in self-management, potentially extending to populations with other chronic health conditions.

METHODS AND ANALYSIS

This mixed-methods observational study involves a (1) prestudy interview and questionnaires, (2) a 24-hour period during which participants wear a camera and complete a time-use diary, and a (3) poststudy interview and study feedback. Adult participants living with type 2 diabetes with at least one chronic comorbidity will be recruited using purposive sampling to obtain a balanced gender ratio and of participants using insulin and those using only oral medication. Interviews will be analysed using thematic analysis. Data captured by digital devices, diaries and questionnaires will be used to analyse the duration, time, context and patterns of health-related behaviours.

ETHICS AND DISSEMINATION

The study was approved by the Macquarie University Human Research Ethics Committee for Medical Sciences (reference number 5201700718). Participants will carry a wallet-sized card that explains the purpose of the study to third parties, and can remove the camera at any stage. Before the poststudy interview begins, participants will view the camera images in private and can delete any images. Should any images be used in future publications or presentations, identifying features such as human faces and names will be obscured.

Uncovering the invisible patient work system through a case study of breast cancer self-management

As patients transition from passive recipients to actors in their health management, there is an opportunity to enhance theoretical frameworks describing the patient work system. Previous macroergonomic frameworks depict how patients manage health outside the institutional healthcare system, though none formally integrate the concept of invisible work - self-management practices undervalued or unseen by healthcare providers. This article overlays invisible work onto the patient work system through a case study of breast cancer self-management. Thirty breast cancer survivors were interviewed about positive and negative experiences post-diagnosis. Invisible and visible components of participants' work systems were explicated through qualitative content analysis. The results demonstrate that all participants had invisible work system components, and based on these findings, this article theorises the existence of an 'invisible patient work system.' Future research and design to support self-management practices should explicitly address the invisible characteristics of the work systems in which patients are embedded.Practitioner Summary: This article seeks to enhance the healthcare human factors literature by integrating the concept of invisible work into preexisting patient work system models. Through a secondary analysis of an interview study with 30 breast cancer survivors, we found that all participants recalled invisible components of their respective work systems. Abbreviations CHIT Consumer Health Information Technology SEIPS Systems Engineering Initiative for Patient Safety IRB Institutional Review Board SES Socioeconomic Status mHealth Mobile Health PHR Patient Health Record ICAN Instrument for Patient Capacity Assessment HIPAA Health Insurance Portability and Accoutability Act.

Challenges And Opportunities For Improving Patient Safety Through Human Factors And Systems Engineering

Despite progress on patient safety since the publication of the Institute of Medicine's 1999 report, To Err Is Human, significant problems remain. Human factors and systems engineering (HF/SE) has been increasingly recognized and advocated for its value in understanding, improving, and redesigning processes for safer care, especially for complex interacting sociotechnical systems. However, broad awareness of HF/SE and its adoption into safety improvement work have been frustratingly slow. We provide an overview of HF/SE, its demonstrated value to a wide range of patient safety problems (in particular, medication safety), and challenges to its broader implementation across health care. We make a variety of recommendations to maximize the spread of HF/SE, including formal and informal education programs, greater adoption of HF/SE by health care organizations, expanded funding to foster more clinician-engineer partnerships, and coordinated national efforts to design and operationalize a system for spreading HF/SE into health care nationally.

Home is where the head is: a distributed cognition account of personal health information management in the home among those with chronic illness

Managing chronic illness requires personal health information management (PHIM) to be performed by lay individuals. Paramount to understanding the PHIM process is understanding the sociotechnical system in which it frequently occurs: the home environment. We combined distributed cognition theory and the patient work system model to investigate how characteristics of the home interact with the cognitive work of PHIM. We used a 3D virtual reality CAVE that enabled participants who had been diagnosed with diabetes (N = 20) to describe how they would perform PHIM in the home context. We found that PHIM is distinctly cognitive work, and rarely performed 'in the head'. Rather, features of the physical environment, tasks, people, and tools and technologies present, continuously shape and are shaped by the PHIM process. We suggest that approaches in which the individual (sans context) is considered the relevant unit of analysis overlook the pivotal role of the environment in shaping PHIM. Practitioner Summary: We examined how Personal Health Information Management (PHIM) is performed in the homes of diabetic patients. We found that approaches to studying cognition that focus on the individual, to the exclusion of their context, overlook the pivotal role of environmental, social, and technological features in shaping PHIM.

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.

Medication management strategies used by older adults with heart failure: A systems-based analysis

BACKGROUND

Older adults with heart failure use strategies to cope with the constraining barriers impeding medication management. Strategies are behavioral adaptations that allow goal achievement despite these constraining conditions. When strategies do not exist, are ineffective or maladaptive, medication performance and health outcomes are at risk. While constraints to medication adherence are described in literature, strategies used by patients to manage medications are less well-described or understood.

AIM

Guided by cognitive engineering concepts, the aim of this study was to describe and analyze the strategies used by older adults with heart failure to achieve their medication management goals.

METHODS

This mixed methods study employed an empirical strategies analysis method to elicit medication management strategies used by older adults with heart failure. Observation and interview data collected from 61 older adults with heart failure and 31 caregivers were analyzed using qualitative content analysis to derive categories, patterns and themes within and across cases.

RESULTS

Data derived thematic sub-categories described planned and ad hoc methods of strategic adaptations. Stable strategies proactively adjusted the medication management process, environment, or the patients themselves. Patients applied situational strategies (planned or ad hoc) to irregular or unexpected situations. Medication non-adherence was a strategy employed when life goals conflicted with medication adherence. The health system was a source of constraints without providing commensurate strategies.

CONCLUSIONS

Patients strived to control their medication system and achieve goals using adaptive strategies. Future patient self-mangement research can benefit from methods and theories used to study professional work, such as strategies analysis.

Medication adherence: staying within the boundaries of safety

An important domain of patient safety is the management of medications in home and community settings by patients and their caregiving network. This study applied human factors/ergonomics theories and methods to data about medication adherence collected from 61 patients with heart failure accompanied by 31 informal caregivers living in the US. Seventy non-adherence events were identified, described, and analysed for performance shaping factors. Half were classified as errors and half as violations. Performance shaping factors included elements of the person or team (e.g. patient limitations), task (e.g. complexity), tools and technologies (e.g. tool quality) and organisational, physical, and social context (e.g. resources, support, social influence). Study findings resulted in a dynamic systems model of medication safety applicable to patient medication adherence and the medication management process. Findings and the resulting model offer implications for future research on medication adherence, medication safety interventions, and resilience in home and community settings. Practitioner Summary: We describe situational and habitual errors and violations in medication use among older patients and their family members. Multiple factors pushed performance towards risk and harm. These factors can be the target for redesign or various forms of support, such as education, changes to the plan of care, and technology design.

An East-West comparison of self-care barriers in heart failure

BACKGROUND

Barriers in heart failure self-care contribute to heart failure hospitalizations, but geographic differences have not been well-studied. We aimed to compare self-care barriers in heart failure patients managed at tertiary centers in an Eastern (Singapore) versus a Western (USA) nation.

METHODS

Acute heart failure patients were prospectively assessed with a standardized instrument comprising of 47 distinct self-care barriers. The multi-equation generalized structural equation model was used to evaluate for geographic differences in barriers experienced, and association of barriers with outcomes.

RESULTS

Patient-related factors accounted for six out of 10 most prevalent self-care barriers among the 90 patients, with a median number of 11 barriers reported per patient. The Western patients reported a higher level of barriers when compared with their Eastern counterparts (median (interquartile range) 15 (9-24) versus 9 (4-16), p=0.001), after adjusting for demographics and co-morbidities. Many of these differences could be explained by geographic differences between the countries. There was no significant difference identified in all-cause mortality (19.4% versus 10.2%) and heart failure re-hospitalization (41.9% versus 45.8%) at six months between the groups.

CONCLUSIONS

Self-care barriers are highly prevalent among acute heart failure patients, and differ substantially between East and West, but were not associated with geographic differences in outcomes.

Know thy eHealth user: Development of biopsychosocial personas from a study of older adults with heart failure

BACKGROUND

Personas are a canonical user-centered design method increasingly used in health informatics research. Personas-empirically-derived user archetypes-can be used by eHealth designers to gain a robust understanding of their target end users such as patients.

OBJECTIVE

To develop biopsychosocial personas of older patients with heart failure using quantitative analysis of survey data.

METHOD

Data were collected using standardized surveys and medical record abstraction from 32 older adults with heart failure recently hospitalized for acute heart failure exacerbation. Hierarchical cluster analysis was performed on a final dataset of n=30. Nonparametric analyses were used to identify differences between clusters on 30 clustering variables and seven outcome variables.

RESULTS

Six clusters were produced, ranging in size from two to eight patients per cluster. Clusters differed significantly on these biopsychosocial domains and subdomains: demographics (age, sex); medical status (comorbid diabetes); functional status (exhaustion, household work ability, hygiene care ability, physical ability); psychological status (depression, health literacy, numeracy); technology (Internet availability); healthcare system (visit by home healthcare, trust in providers); social context (informal caregiver support, cohabitation, marital status); and economic context (employment status). Tabular and narrative persona descriptions provide an easy reference guide for informatics designers.

DISCUSSION

Personas development using approaches such as clustering of structured survey data is an important tool for health informatics professionals. We describe insights from our study of patients with heart failure, then recommend a generic ten-step personas development process. Methods strengths and limitations of the study and of personas development generally are discussed.

Infinicare framework for integrated understanding of health-related activities in clinical and daily-living contexts

Clinical and consumer health informatics interventions promise to transform health care, yielding higher quality, more accessible care at a lower cost. However, the potential of these interventions cannot be achieved if they are developed and rolled out in a disconnected way: clinic-based systems typically do not interface with home-based systems that capture patient-generated health-related data. The fragmentation between these interventions severely limits the benefits of all interventions; given that health care is a continuum between clinical and daily-living settings. We introduce the Infinicare framework, which posits that clinical health-related activities "shape" daily-living-based health-related activities and, conversely, that daily-living-based health-related activities "inform" activities in clinics. Non-alignment of activities across these diverse contexts yields systemic gaps. Workflow studies that capture health-related activities and characterise gaps between clinical and daily-living contexts can inform the design and implementation of gap-filling, collaborative health information technologies. To inform these technologies, workflow studies should be patient-oriented, include both clinical and daily-living settings and subsume both process and structure variables. Novel methodologies are needed to effectively and efficiently capture health-related activities across both clinical and daily-living settings and their contexts. Guidelines for applying these recommendations in developing collaborative health information technologies are provided.

Human factors in mental healthcare: A work system analysis of a community-based program for older adults with depression and dementia

Mental healthcare is a critical but largely unexplored application domain for human factors/ergonomics. This paper reports on a work system evaluation of a home-based dementia and depression care program for older adults, the Aging Brain Care program. The Workflow Elements Model was used to guide data collection and analysis of 59 h of observation, supplemented by key informant input. We identified four actors, 37 artifacts across seven types, ten action categories, and ten outcomes including improved health and safety. Five themes emerged regarding barriers and facilitators to care delivery in the program: the centrality of relationship building; the use of adaptive workarounds; performance of duplicate work; travel and scheduling challenges; and communication-related factors. Findings offer new insight into how mental healthcare services are delivered in a community-based program and key work-related factors shaping program outcomes.