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.

Patient ergonomics: 10-year mapping review of patient-centered human factors

Patient ergonomics is the application of human factors or related disciplines to study and improve patients' and other non-professionals' performance of effortful work activities in pursuit of health goals. We performed a mapping review of 212 full-text patient ergonomics publications in two conference proceedings, 2007-2017. The review revealed a robust and growing body of literature on patient ergonomics, particularly in the areas of aging and chronic disease, tools and technologies, and evaluations of patient-centered interventions on outcomes such as usability, user acceptance, and performance. Findings highlighted gaps deserving future research, including research with understudied populations such as children, informal caregivers, networks and collectives (groups), and marginalized populations; on topics such as health promotion and transitions of care; and using longitudinal and experimental study designs. The growth of patient-centeredness in general and of patient ergonomics in particular compel other more focused reviews, new primary research, and developing a roadmap for future patient ergonomics research.

The spatial dimensions of medication management by home-dwelling older adults after hospital discharge

Ageing in place raises pressing questions about medication practices at home. Understanding how medication practices are integrated into older adults' domestic settings requires an interest in where activities linked to medication take place and why. This study aimed to describe the medication practices and spatial dimensions of medication management for home-dwelling older adults after hospital discharge, using a qualitative research design. Semi-structured interviews were carried out with ten older adults aged 65 years old or more and discharged home from hospital, together with nine informal caregivers. Thematic content analysis identified two main themes dealing with the spatial dimensions of medication management in this specific context: the process of integrating medication changes into routines and familiar spaces, and the individual and collective management of medication changes linked to a renegotiation of the boundaries between public and private spaces.

Naturalistic Decision Making by Older Adults with Chronic Heart Failure: An Exploratory Study Using the Critical Incident Technique

Older adults with chronic heart failure (CHF) make daily decisions to manage their disease, with some of these decisions resulting in major health outcomes such as acute decompensation, hospitalization, and death. To understand how older adults with CHF make these decisions in their natural sociotechnical system context, we analyzed data from critical incident technique interviews with 12 older adults with CHF and 6 (family or friend) support persons. We identified key decision-making barriers, strategies, and distributed activity in stages of monitoring information or data, interpreting the information, and acting as a result. Our findings contribute to the broader research literature on CHF self-care as a naturalistic phenomenon and can aid in the exploration of design requirements for the development of technologies and interventions to assist in heart failure self-management.

User-Centered Evaluations with Older Adults: Testing the Usability of a Mobile Health System for Heart Failure Self-Management

Many older adults living with heart failure struggle to follow recommended self-management routines. To help older adults with heart failure more effectively and efficiently self-manage their disease, we developed Engage, a mobile health application promoting the performance, logging, and sharing of routine self-management behaviors. This paper reports on the usability evaluation of the Engage system with 15 older adults with heart failure and informal caregivers. In two phases, participants used Engage during a task-based usability test (n=5) and a scenario-based usability test (n=10). Usability and performance data were assessed through video-recorded observation and the administration of the system usability scale (SUS) and NASA Task Load Index (TLX). We found that task-based testing was useful in quickly identifying problems within our application, but scenario-based testing elicited more valuable feedback from older adults. A comparison of the different evaluation methods used and the discussion of the challenges encountered provide multiple implications for the practice of usability testing of mobile health products with older adults.

Capturing the Medication Management Work System of Older Adults Using a Digital Diary Method

Human Factors and Ergonomics (HFE) has the potential to transform the lives of older adults by helping them better manage their health and disease. Older adults are often beset with multiple chronic illnesses and struggle to manage complex medication regimens. Non-adherence, errors, and poor outcomes are common. New research shows that patients’ health-related activities constitute an effortful, goal-driven type of work called patient work. HFE can play a major role in the study and improvement of patient work performance but current HFE methods are not fully suitable. This is in part because patient work is variable and takes place in home and community settings dissimilar to those commonly studied by healthcare HFE researchers. The objective of this study was to perform a work systems analysis of the medication management work of older adults with heart failure by adapting a method more suitable for the study of patient work. This qualitative longitudinal study used an innovative digital diary data collection method. Fifteen older adults with heart failure made medication-related multimedia recordings over a one-week period followed by an interview. These data were content analyzed according to the Patient Work System model. Results identified 6 organizational (70 instances), 7 task (45 instances), 7 tool (31 instances), 6 patient (31 instances), 4 social (21 instances), and 2 physical work system factors (10 instances). Patient medication performance suffered from a lack of care coordination and integration. Organizational tools such as mail order delivery facilitated access, but many patients devised tools and strategies to address other barriers. The study concluded that there is a need to design task-relevant tools to support and optimize the patients’ medication management work systems.

Human factors analysis, design, and evaluation of Engage, a consumer health IT application for geriatric heart failure self-care

Human factors and ergonomics (HFE) and related approaches can be used to enhance research and development of consumer-facing health IT systems, including technologies supporting the needs of people with chronic disease. We describe a multiphase HFE study of health IT supporting self-care of chronic heart failure by older adults. The study was based on HFE frameworks of "patient work" and incorporated the three broad phases of user-centered design: study or analysis; design; and evaluation. In the study phase, data from observations, interviews, surveys, and other methods were analyzed to identify gaps in and requirements for supporting heart failure self-care. The design phase applied findings from the study phase throughout an iterative process, culminating in the design of the Engage application, a product intended for continuous use over 30 days to stimulate self-care engagement, behavior, and knowledge. During the evaluation phase, we identified a variety of usability issues through expert heuristic evaluation and laboratory-based usability testing. We discuss the implications of our findings regarding heart failure self-care in older adults and the methodological challenges of rapid translational field research and development in this domain.

Mind the gulfs: An analysis of medication-related cognitive artifacts used by older adults with heart failure

Medication management is a patient health-related activity characterized by poor performance in older adults with chronic disease. Interventions focus on educating and motivating the patient with limited long-term effects. Cognitive artifacts facilitate cognitive tasks by making them easier, faster, and more effective and can potentially improve medication management performance. This study examined how older adult patients with heart failure use cognitive artifacts and how representational structure and physical properties facilitated or impeded medication-related tasks and processes. Interview, observation, medical record, and photographic data of and about older patients with heart failure (N = 30) and their informal caregivers (N=14) were content analyzed for cross-cutting themes about patient goals, representations, and actions. Results illustrated patient artifacts designed from a clinical rather than patient perspective, disparate internal and external representations threatening safety, and incomplete information exchange between patients and clinicians. Implications for design were the need for bridging artifacts, automatic information transfer, and cognitive artifacts designed from the perspective of the patient.

Patient Work as a Maturing Approach Within HF/E

Over the last five years, human factors and ergonomics (HF/E) applications in healthcare have expanded beyond the institution to encompass the homes and communities of patients. The patient work approach has been developed as a means of formalizing the theoretical and methodological foundations of applying HF/E within this new domain. Early applications of the patient work approach were confined to studies of relatively straightforward self-management tasks. As the patient work approach matures, however, its application is spreading to more complex subdomains of health management in home and community settings. This panel will focus on cutting edge application and methodological areas of patient work. Each panelist will introduce their work, present challenges related to expanding the patient work approach in a new direction, and engage with audience members to address these challenges and brainstorm ways in which the patient work approach can be further adapted to more intricate healthcare challenges.

Self-care Barriers Reported by Emergency Department Patients With Acute Heart Failure: A Sociotechnical Systems-Based Approach

STUDY OBJECTIVE

We pilot tested a sociotechnical systems-based instrument that assesses the prevalence and nature of self-care barriers among patients presenting to the emergency department (ED) with acute heart failure.

METHODS

A semistructured instrument for measuring self-reported self-care barriers was developed and administered by ED clinicians and nonclinician researchers to 31 ED patients receiving a diagnosis of acute heart failure. Responses were analyzed with descriptive statistics and qualitative content analysis. Feasibility was assessed by examining participant cooperation rates, instrument completion times, item nonresponse, and data yield.

RESULTS

Of 47 distinct self-care barriers assessed, a median of 15 per patient were indicated as "sometimes" or "often" present. Thirty-four specific barriers were reported by more than 25% of patients and 9 were reported by more than 50%. The sources of barriers included the person, self-care tasks, tools and technologies, and organizational, social, and physical contexts. Seven of the top 10 most prevalent barriers were related to patient characteristics; the next 3, to the organizational context (eg, life disruptions). A preliminary feasibility assessment found few item nonresponses or comprehension difficulties, good cooperation, and high data yield from both closed- and open-ended items, but also found opportunities to reduce median administration time and variability.

CONCLUSION

An instrument assessing self-care barriers from multiple system sources can be feasibly implemented in the ED. Further research is required to modify the instrument for widespread use and evaluate its implementation across institutions and cultural contexts. Self-care barriers measurement can be one component of broader inquiry into the distributed health-related "work" activity of patients, caregivers, and clinicians.

The patient work system: an analysis of self-care performance barriers among elderly heart failure patients and their informal caregivers

Human factors and ergonomics approaches have been successfully applied to study and improve the work performance of healthcare professionals. However, there has been relatively little work in "patient-engaged human factors," or the application of human factors to the health-related work of patients and other nonprofessionals. This study applied a foundational human factors tool, the systems model, to investigate the barriers to self-care performance among chronically ill elderly patients and their informal (family) caregivers. A Patient Work System model was developed to guide the collection and analysis of interviews, surveys, and observations of patients with heart failure (n = 30) and their informal caregivers (n = 14). Iterative analyses revealed the nature and prevalence of self-care barriers across components of the Patient Work System. Person-related barriers were common and stemmed from patients' biomedical conditions, limitations, knowledge deficits, preferences, and perceptions as well as the characteristics of informal caregivers and healthcare professionals. Task barriers were also highly prevalent and included task difficulty, timing, complexity, ambiguity, conflict, and undesirable consequences. Tool barriers were related to both availability and access of tools and technologies and their design, usability, and impact. Context barriers were found across three domains-physical-spatial, social-cultural, and organizational-and multiple "spaces" such as "at home," "on the go," and "in the community." Barriers often stemmed not from single factors but from the interaction of several work system components. Study findings suggest the need to further explore multiple actors, contexts, and interactions in the patient work system during research and intervention design, as well as the need to develop new models and measures for studying patient and family work.