Understanding Clinicians' Adoption of Mobile Health Tools: A Qualitative Review of the Most Used Frameworks

Successful Electronic Consultation Service Initiative in Quebec, Canada With Primary Care Physicians' and Specialists' Experiences on Acceptance and Use of Technological Innovation: Cross-Sectional Exploratory Study

BACKGROUND

Electronic consultation (eConsult) is an eHealth service that allows primary care providers (PCPs) to electronically consult specialists regarding their patients' medical issues. Many studies have demonstrated that eConsult services improve timely access to specialist care; prevent unnecessary referrals; improve PCPs', specialists', and patients' satisfaction; and therefore have a large impact on costs. However, no studies have evaluated PCPs' and specialists' acceptance of eConsult services in Quebec, Canada, and worldwide.

OBJECTIVE

This exploratory study aims to identify factors affecting eConsult service acceptance by PCPs and specialists in urban and rural primary care clinics across 3 regions in the province of Quebec, Canada, by integrating the Unified Theory of Acceptance and Use of Technology and Task-Technology Fit (TTF) models and user satisfaction. This research was designed to broaden and assist in scaling up this effective eHealth service innovation across the province.

METHODS

A cross-sectional web-based survey was sent to all PCPs (n=263) and specialists (n=62) who used the eConsult Quebec Service between July 2017 and May 2021. We proposed a unified model integrating the Unified Theory of Acceptance and Use of Technology model and TTF model and user satisfaction by endorsing 11 hypotheses. The partial least squares was used to investigate factors influencing the acceptance of the eConsult Quebec Service.

RESULTS

Of the 325 end users, 136 (41.8%) users responded (PCPs: 101/263, 38.4%; specialists: 35/62, 57%). The results of the analysis with partial least squares method indicate that 9 of our 11 hypotheses are supported. The direct relationships uniting the various constructs of the model highlighted the importance of several key constructs and predominant correlations. The results suggest that satisfaction is the key driver behind the use of the eConsult Quebec Service. Performance expectancy (P<.001) and effort expectancy (P=.03) can have a positive impact on behavioral intention (BI), and BI (P<.001) can impact adoption. TTF has an influence on performance expectancy (P<.001), adoption (P=.02), and satisfaction (P<.001). However, the results show that there is no direct effect between social influence (P=.38) and BI or between facilitating conditions (P=.17) and adoption.

CONCLUSIONS

This study provides a better understanding of the factors influencing PCPs' and specialists' intention to adopt the eConsult Quebec Service. Furthermore, this study tests a research model and a technology that have never been explored in Quebec until now. On the basis of the results, the service is a good fit to meet the users' need to improve access to specialized medical advice. Therefore, the results of our study have made a valuable contribution to the implementation of the service by policy makers in order to maximize acceptance, use, adoption, and success across the province of Quebec. Moreover, after 4 successful years, the eConsult Quebec pilot project is now the Conseil Numérique digital consultation service.

Assessment of the Barriers and Enablers of the Use of mHealth Systems in Sub-Saharan Africa According to the Perceptions of Patients, Physicians, and Health Care Executives in Ethiopia: Qualitative Study

BACKGROUND

Digital technologies are increasingly being used to deliver health care services and promote public health. Mobile wireless technologies or mobile health (mHealth) technologies are particularly relevant owing to their ease of use, broad reach, and wide acceptance. Unlike developed countries, Sub-Saharan Africa experiences more challenges and obstacles when it comes to deploying, using, and expanding mHealth systems. In addition to barriers, there are enabling factors that could be exploited for the design, implementation, and scaling up of mHealth systems. Sub-Saharan Africa may require tailored solutions that address the specific challenges facing the region.

OBJECTIVE

The overall aim of this study was to identify the barriers and enablers for using mHealth systems in Sub-Saharan Africa from the perspectives of patients, physicians, and health care executives.

METHODS

Multi-level and multi-actor in-depth semistructured interviews were employed to qualitatively explore the barriers and enablers of the use of mHealth systems. Data were collected from patients, physicians, and health care executives. The interviews were audio recorded, transcribed verbatim, translated, and coded. Thematic analysis methodology was adopted, and NVivo software was used for the data analysis.

RESULTS

Through this rigorous study, a total of 137 determinants were identified. Of these determinants, 68 were identified as barriers and 69 were identified as enablers. Perceived barriers in patients included lack of awareness about mHealth systems and language barriers. Perceived enablers in patients included need for automated tools for health monitoring and an increasing literacy level of the society. According to physicians, barriers included lack of available digital health systems in the local context and concern about patients' mHealth capabilities, while enablers included the perceived usefulness in reducing workload and improving health care service quality, as well as the availability of mobile devices and the internet. As perceived by health care executives, barriers included competing priorities alongside digitalization in the health sector and lack of interoperability and complete digitalization of implemented digital health systems, while enablers included the perceived usefulness of digitalization for the survival of the highly overloaded health care system and the abundance of educated manpower specializing in technology.

CONCLUSIONS

mHealth systems in Sub-Saharan Africa are hindered and facilitated by various factors. Common barriers and enablers were identified by patients, physicians, and health care executives. To promote uptake, all relevant stakeholders must actively mitigate the barriers. This study identified a promising outlook for mHealth in Sub-Saharan Africa, despite the present barriers. Opportunities exist for successful integration into health care systems, and a user-centered design is crucial for maximum uptake.

A sociotechnical framework to assess patient-facing eHealth tools: results of a modified Delphi process

Among the thousands of eHealth tools available, the vast majority do not get past pilot phases because they cannot prove value, and only a few have been systematically assessed. Although multiple eHealth assessment frameworks have been developed, these efforts face multiple challenges. This study aimed to address some of these challenges by validating and refining an initial list of 55 assessment criteria based on previous frameworks through a two-round modified Delphi process with in-between rounds of interviews. The expert panel (n = 57) included participants from 18 countries and 9 concerned parties. A consensus was reached on 46 criteria that were classified into foundational and contextual criteria. The 36 foundational criteria focus on evaluating the eHealth tool itself and were grouped into nine clusters: technical aspects, clinical utility and safety, usability and human centricity, functionality, content, data management, endorsement, maintenance, and developer. The 10 contextual criteria focus on evaluating the factors that vary depending on the context the tool is being evaluated for and were grouped into seven clusters: data-protection compliance, safety regulatory compliance, interoperability and data integration, cultural requirements, affordability, cost-benefit, and implementability. The classification of criteria into foundational and contextual helps us assess not only the quality of an isolated tool, but also its potential fit in a specific setting. Criteria subscales may be particularly relevant when determining the strengths and weaknesses of the tool being evaluated. This granularity enables different concerned parties to make informed decisions about which tools to consider according to their specific needs and priorities.

Exploring the Incorporation of a Novel Cardiotoxicity Mobile Health App Into Care of Patients With Cancer: Qualitative Study of Patient and Provider Perspectives

BACKGROUND

Cardiotoxicity is a limitation of several cancer therapies and early recognition improves outcomes. Symptom-tracking mobile health (mHealth) apps are feasible and beneficial, but key elements for mHealth symptom-tracking to indicate early signs of cardiotoxicity are unknown.

OBJECTIVE

We explored considerations for the design of, and implementation into a large academic medical center, an mHealth symptom-tracking tool for early recognition of cardiotoxicity in patients with cancer after cancer therapy initiation.

METHODS

We conducted semistructured interviews of >50% of the providers (oncologists, cardio-oncologists, and radiation oncologists) who manage cancer treatment-related cardiotoxicity in the participating institution (n=11), and either interviews or co-design or both with 6 patients. Data were coded and analyzed using thematic analysis.

RESULTS

Providers indicated that there was no existing process to enable early recognition of cardiotoxicity and felt the app could reduce delays in diagnosis and lead to better patient outcomes. Signs and symptoms providers recommended for tracking included chest pain or tightness, shortness of breath, heart racing or palpitations, syncope, lightheadedness, edema, and excessive fatigue. Implementation barriers included determining who would receive symptom reports, ensuring all members of the patient's care team (eg, oncologist, cardiologist, and primary care) were informed of the symptom reports and could collaborate on care plans, and how to best integrate the app data into the electronic health record. Patients (n=6, 100%) agreed that the app would be useful for enhanced symptom capture and education and indicated willingness to use it.

CONCLUSIONS

Providers and patients agree that a patient-facing, cancer treatment-related cardiotoxicity symptom-tracking mHealth app would be beneficial. Additional studies evaluating the role of mHealth as a potential strategy for targeted early cardioprotective therapy initiation are needed.

An Online Learning Experience Simulating Video Telehealth with Older Adults: Student Perceptions

Older adults are an underserved population with a broad-spectrum of care needs due to multi-morbidity, including increasing rates of mental health conditions. Though a prime target for tele-behavioral health due to access barriers, older adults face a persistent digital divide that necessitates clinician training and education to ensure interprofessional tele-behavioral health is tailored to their needs. This paper presents findings from a simulation learning program designed to teach students about the role of video telehealth with populations with diverse needs. Occupational therapy (OT) students enrolled in a Master's program between 2017 and 2018 conducted a simulated video telehealth session geared for an older adult. Sessions were recorded and annotated by students, who then provided feedback on their experience of the simulation via reflective essays (N = 27). Essays were analyzed using conventional content analysis with themes revealing the benefits of simulation in providing students with an opportunity to experience the often unpredictable nature of video telehealth. Themes also revealed perceived limitations of video and the negative impact of age-related conditions and age itself on older adults' ability to engage in video, reflecting ageist stereotyping and bias as potential barriers to novice practitioners' integration of video telehealth with older adults. Simulation provides students an opportunity to engage in active learning and problem-solving in the moment, fostering students' development of clinical reasoning while promoting reflective practice. Findings reveal the importance of supporting students' recognition of biased attitudes to ensure equitable application of tele-behavioral health care, especially to populations with complex needs.

Modelling the Predictors of Mobile Health (mHealth) Adoption among Healthcare Professionals in Low-Resource Environments

This study was conducted with objectives to measure and validate the unified theory of the acceptance and use of technology (UTAUT) model as well as to identify the predictors of mobile health (mHealth) technology adoption among healthcare professionals in limited-resource settings. A cross-sectional survey was conducted at the six public and private hospitals in the two districts (Lodhran and Multan) of Punjab, Pakistan. The participants of the study comprised healthcare professionals (registered doctors and nurses) working in the participating hospitals. The findings of the seven-factor measurement model showed that behavioral intention (BI) to mHealth adoption is significantly influenced by performance expectancy (β = 0.504, CR = 5.064, p < 0.05) and self-concept (β = 0.860, CR = 5.968, p < 0.05) about mHealth technologies. The findings of the structural equation model (SEM) showed that the model is acceptable (χ2 (df = 259) = 3.207; p = 0.000; CFI = 0.891, IFI = 0.892, TLI = 0.874, RMSEA = 0.084). This study suggests that the adoption of mHealth can significantly help in improving people's access to quality healthcare resources and services as well as help in reducing costs and improving healthcare services. This study is significant in terms of identifying the predictors that play a determining role in the adoption of mHealth among healthcare professionals. This study presents an evidence-based model that provides an insight to policymakers, health organizations, governments, and political leaders in terms of facilitating, promoting, and implementing mHealth adoption plans in low-resource settings, which can significantly reduce health disparities and have a direct impact on health promotion.

How WhatsApp is transforming health communication among frontline health workers: a mixed-method study among midwives in India

BACKGROUND

Limited literature exists in India on WhatsApp use for health communication among frontline health workers like Auxiliary Nurse Midwives (ANM). We conducted this study to assess the adoption of WhatsApp among ANMs and identify factors influencing its adoption. In addition, the study explored the perceptions of ANMs on WhatsApp use for sharing health information.

METHODS

We employed a mixed-method sequential explanatory design. We surveyed 259 ANMs, followed by in-depth interviews with 19 purposively sampled ANMs. We conducted multinomial logistic regression to identify factors associated with WhatsApp adoption and employed thematic analysis to analyze interviews.

RESULTS

257 ANMs responded to the survey questionnaire, of which 18.3%, 48.2%, and 33.5% had low, mid, and high levels of WhatsApp adoption, respectively. Education (AOR = 2.87 [95% CI = 1.20-6.85]), motivation (AOR = 6.31 [95% CI = 1.43-27.80]), and technical awareness (AOR = 2.91 [95% CI = 1.11-7.62]) were significantly associated with WhatsApp adoption. Thematic analysis of the interviews resulted in six themes describing perceptions and experiences of ANMs on WhatsApp use. They are: (i) a way of instant communication, (ii) provision for multimedia messaging, (iii) a quick fix tool for queries and concerns, (iv) make attendance and reporting easy (v) a way of reaching higher officials, and (vi) a cost-saving mechanism.

CONCLUSION

WhatsApp facilitated ANMs' communication and service delivery at the grassroots level. Measures to improve motivation, technical awareness, and digital education will likely improve WhatsApp adoption among health workers.

Female youth and mental health service providers' perspectives on the JoyPop™ app: a qualitative study

Introduction

Mobile health (mHealth) apps are a promising adjunct to traditional mental health services, especially in underserviced areas. Developed to foster resilience in youth, the JoyPop™ app has a growing evidence base showing improvement in emotion regulation and mental health symptoms among youth. However, whether this novel technology will be accepted among those using or providing mental health services remains unknown. This study aimed to evaluate the JoyPop™ app's acceptance among (a) a clinical sample of youth and (b) mental health service providers.

Method

A qualitative descriptive approach involving one-on-one semi-structured interviews was conducted. Interviews were guided by the Technology Acceptance Model and were analyzed using a deductive-inductive content analysis approach.

Results

All youth (n = 6 females; Mage = 14.60, range 12-17) found the app easy to learn and use and expressed positive feelings towards using the app. Youth found the app useful because it facilitated accessibility to helpful coping skills (e.g., journaling to express their emotions; breathing exercises to increase calmness) and positive mental health outcomes (e.g., increased relaxation and reduced stress). All service providers (n = 7 females; Mage = 43.75, range 32-60) perceived the app to be useful and easy to use by youth within their services and expressed positive feelings about integrating the app into usual care. Service providers also highlighted various organizational factors affecting the app's acceptance. Youth and service providers raised some concerns about apps in general and provided recommendations to improve the JoyPop™ app.

Discussion

Results support youth and service providers' acceptance of the JoyPop™ app and lend support for it as an adjunctive resource to traditional mental health services for youth with emotion regulation difficulties.

Feasibility of Implementation of a Mobile Digital Personal Health Record to Coordinate Care for Children and Youth With Special Health Care Needs in Primary Care: Protocol for a Mixed Methods Study

BACKGROUND

Electronic health record (EHR)-integrated digital personal health records (PHRs) via Fast Healthcare Interoperability Resources (FHIR) are promising digital health tools to support care coordination (CC) for children and youth with special health care needs but remain widely unadopted; as their adoption grows, mixed methods and implementation research could guide real-world implementation and evaluation.

OBJECTIVE

This study (1) evaluates the feasibility of an FHIR-enabled digital PHR app for CC for children and youth with special health care needs, (2) characterizes determinants of implementation, and (3) explores associations between adoption and patient- or family-reported outcomes.

METHODS

This nonrandomized, single-arm, prospective feasibility trial will test an FHIR-enabled digital PHR app's use among families of children and youth with special health care needs in primary care settings. Key app features are FHIR-enabled access to structured data from the child's medical record, families' abilities to longitudinally track patient- or family-centered care goals, and sharing progress toward care goals with the child's primary care provider via a clinician dashboard. We shall enroll 40 parents or caregivers of children and youth with special health care needs to use the app for 6 months. Inclusion criteria for children and youth with special health care needs are age 0-16 years; primary care at a participating site; complex needs benefiting from CC; high hospitalization risk in the next 6 months; English speaking; having requisite technology at home (internet access, Apple iOS mobile device); and an active web-based EHR patient portal account to which a parent or caregiver has full proxy access. Digital prescriptions will be used to disseminate study recruitment materials directly to eligible participants via their existing EHR patient portal accounts. We will apply an intervention mixed methods design to link quantitative and qualitative (semistructured interviews and family engagement panels with parents of children and youth with special health care needs) data and characterize implementation determinants. Two CC frameworks (Pediatric Care Coordination Framework; Patient-Centered Medical Home) and 2 evaluation frameworks (Consolidated Framework for Implementation Research; Technology Acceptance Model) provide theoretical foundations for this study.

RESULTS

Participant recruitment began in fall 2022, before which we identified >300 potentially eligible patients in EHR data. A family engagement panel in fall 2021 generated formative feedback from family partners. Integrated analysis of pretrial quantitative and qualitative data informed family-centered enhancements to study procedures.

CONCLUSIONS

Our findings will inform how to integrate an FHIR-enabled digital PHR app for children and youth with special health care needs into clinical care. Mixed methods and implementation research will help strengthen implementation in diverse clinical settings. The study is positioned to advance knowledge of how to use digital health innovations for improving care and outcomes for children and youth with special health care needs and their families.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05513235; https://clinicaltrials.gov/study/NCT05513235.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/46847.

Enablers and inhibitors to the adoption of mHealth apps by patients - A qualitative analysis of German doctors' perspectives

OBJECTIVE

Germany is the first country that approved validated mobile health apps (called DiGA) for prescription by doctors and psychotherapists. The aim of this study is to investigate doctors' perspectives towards these mobile health apps and their intentions to prescribe them. Additionally, we investigated the influence of different roles and expectations of outcomes.

METHODS

We used a qualitative study design to determine doctors' viewpoints on prescribing DiGAs. We conducted 28 semi-structured interviews and used the grounded theory method for analysis. We adopted a classical conceptualist approach to gain theoretical insights.

RESULTS

The results show that doctors' acceptance and support of DiGAs are critical in mobile health uptake and utilisation. Although mobile health is seen to be supportive of patient management and patient education doctors nevertheless need to adopt a motivating and persuasive role in the process.

CONCLUSIONS

Doctors consider DiGAs complementary to their role in patient management and are predominantly positive about DiGAs. A trusted relationship with patients must be developed to ensure the appropriate support of DiGAs.

PRACTICE IMPLICATIONS

Our study suggests that targeted education, user-centred DiGAs, consideration of social presence and user engagement, and co-development with doctors can improve longer-term DiGA use and effectiveness.

Going digital in Germany: An exploration of physicians’ attitudes towards the introduction of electronic prescriptions – a mixed methods approach

PURPOSE

Digitalization of medical prescriptions is a core element for the digitalization of healthcare. While some countries have introduced electronic prescriptions over 20 years ago and nearly reached 100 % penetration, physicians in Germany have only been able to use electronic prescriptions since mid-2021 and currently only 0.1 % of prescriptions are transmitted electronically. This study investigates German physicians' viewpoint towards electronic prescriptions as a potential reason for the low penetration and investigates levers to drive adoption.

BASIC PROCEDURES

We conducted a two-stage sequential mixed methods study consisting of semi-structured interviews followed by an online survey among 1136 physicians testing the main dimensions of the Unified Theory of Acceptance and Use of Technology model.

MAIN FINDINGS

Our initial interviews suggested that there was a high technology acceptance by physicians, but due to technical barriers, they were not able to use the system, explaining the low penetration. However, with the larger sample size of the survey, we identified, that while physicians see barriers for introducing electronic prescriptions, such as unclear cost reimbursement or lack of time to deal with the implementation, the majority believes these can be overcome within twelve months. Furthermore, we found that only one third of physicians is in favor of replacing paper-based prescriptions with electronic prescriptions and most physicians considers it unlikely that they will issue more than half of their prescriptions electronically within the next twelve month. Additionally, respondents perceived limited usefulness and expect high effort for using electronic prescriptions.

PRINCIPAL CONCLUSION

Low electronic prescription penetration in Germany seems to be driven by low technology acceptance, not technical barriers. This can be linked to low perceived usefulness, high effort expectancy and low perceived patient demand. Improving technical stability, system functionality and increasing physicians' level of information were seen as main levers to drive electronic prescription adoption.

Assessing the Quality and Impact of eHealth Tools: Systematic Literature Review and Narrative Synthesis

BACKGROUND

Technological advancements have opened the path for many technology providers to easily develop and introduce eHealth tools to the public. The use of these tools is increasingly recognized as a critical quality driver in health care; however, choosing a quality tool from the myriad of tools available for a specific health need does not come without challenges.

OBJECTIVE

This review aimed to systematically investigate the literature to understand the different approaches and criteria used to assess the quality and impact of eHealth tools by considering sociotechnical factors (from technical, social, and organizational perspectives).

METHODS

A structured search was completed following the participants, intervention, comparators, and outcomes framework. We searched the PubMed, Cochrane, Web of Science, Scopus, and ProQuest databases for studies published between January 2012 and January 2022 in English, which yielded 675 results, of which 40 (5.9%) studies met the inclusion criteria. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and the Cochrane Handbook for Systematic Reviews of Interventions were followed to ensure a systematic process. Extracted data were analyzed using NVivo (QSR International), with a thematic analysis and narrative synthesis of emergent themes.

RESULTS

Similar measures from the different papers, frameworks, and initiatives were aggregated into 36 unique criteria grouped into 13 clusters. Using the sociotechnical approach, we classified the relevant criteria into technical, social, and organizational assessment criteria. Technical assessment criteria were grouped into 5 clusters: technical aspects, functionality, content, data management, and design. Social assessment criteria were grouped into 4 clusters: human centricity, health outcomes, visible popularity metrics, and social aspects. Organizational assessment criteria were grouped into 4 clusters: sustainability and scalability, health care organization, health care context, and developer.

CONCLUSIONS

This review builds on the growing body of research that investigates the criteria used to assess the quality and impact of eHealth tools and highlights the complexity and challenges facing these initiatives. It demonstrates that there is no single framework that is used uniformly to assess the quality and impact of eHealth tools. It also highlights the need for a more comprehensive approach that balances the social, organizational, and technical assessment criteria in a way that reflects the complexity and interdependence of the health care ecosystem and is aligned with the factors affecting users' adoption to ensure uptake and adherence in the long term.

Development of an evaluation framework for health information communication technology in contemporary pharmacy practice

Background

Health information communication technology (ICT) has rapidly evolved in contemporary pharmacy practice worldwide. The Australian healthcare system is experiencing a paradigm shift to real-time interconnectivity for practitioners and consumers and interoperable digital health. With these developments come a need to evaluate use of technologies specifically in pharmacy practice to optimize their clinical functionality. There are no published frameworks for evaluating ICT needs or implementation in pharmacy practice.

Objective

This paper proposes a theoretical framework for evaluating health ICT in pharmacy.

Methods

Development of the evaluation framework was informed by a systematic scoping review and health informatics literature. Specifically, the framework drew upon critical appraisal and concept mapping of the TAM, ISS and HOT-fit validated models, with respect to health ICT in contemporary pharmacy practice.

Results

The proposed model was named the Technology Evaluation Key (TEK). The TEK comprises of 10 domains; healthcare system, organization, practitioner, user interface, ICT, use, operational outcomes, system outcomes, clinical outcomes and timely access to care.

Conclusions

This is the first published proposed evaluation framework developed for health ICT specifically in contemporary pharmacy practice. TEK represents a pragmatic way to ensure the development, refinement and implementation of new and existing technologies in contemporary pharmacy practice to keep pace with the clinical and professional requirements of community pharmacists. Operational, clinical and system outcomes should be evaluated as coexisting factors that may impact implementation. Validation research utilizing Design Science Research Methodology will enhance utility for end users and ensure the relevance and application of the TEK to contemporary pharmacy practice.

Acceptability and Initial Adoption of the Heart Observation App for Infants with Congenital Heart Disease: A Qualitative Study (Preprint)

BACKGROUND

Approximately 1% of all infants are born with a congenital heart disease (CHD). Internationally CHD remains a major cause of infant death, some of which occur unexpectedly after a gradual deterioration at home. Many parents find it difficult to recognize worsening of symptoms.

OBJECTIVE

This study aims to report the acceptability and initial adoption of a mobile app, the Heart Observation app (HOBS), aiming to support parents' understanding and management of their child's condition and to increase quality in follow-up from health care professionals in complex health care services in Norway.

METHODS

A total of 9 families were interviewed on discharge from the neonatal intensive care unit and after 1 month at home. The infant's primary nurse, community nurse, and cardiologist were also interviewed regarding their experiences about collaboration with the family. The interviews were analyzed inductively with thematic content analysis.

RESULTS

The analysis generated 4 main themes related to acceptability and adoption: (1) Individualize Initial Support, (2) Developing Confidence and Coping, (3) Normalize When Appropriate, and (4) Implementation in a Complex Service Pathway. The receptivity of parents to learn and attend in the intervention differs according to their present situation. Health care professionals emphasized the importance of adapting the introduction and guidance to parents' receptivity to ensure comprehension, self-efficacy, and thereby acceptance before discharge (Individualize Initial Support). Parents perceived that HOBS served them well and nurtured confidence by teaching them what to be aware of. Health care professionals reported most parents as confident and informed. This potential effect increased the possibility of adoption (Developing Confidence and Coping). Parents expressed that HOBS was not an "everyday app" and wanted to normalize everyday life when appropriate. Health care professionals suggested differentiating use according to severity and reducing assessments after recovery to adapt the burden of assessments when appropriate (Normalize When Appropriate). Health care professionals' attitude to implement HOBS in their services was positive. They perceived HOBS as useful to systemize guidance, to enhance communication regarding an infant's condition, and to increase understanding of heart defects in health care professionals with sparse experience (Implementation in a Complex Service Pathway).

CONCLUSIONS

This feasibility study shows that both parents and health care professionals found HOBS as a positive addition to the health care system and follow-up. HOBS was accepted and potentially useful, but health care professionals should guide parents initially to ensure comprehension and adapt timing to parents' receptivity. By doing so, parents may be confident to know what to look for regarding their child's health and cope at home. Differentiating between various diagnoses and severity is important to support normalization when appropriate. Further controlled studies are needed to assess adoption, usefulness, and benefits in the health care system.

Healthcare Workers' Perspectives of mHealth Adoption Factors in the Developing World: Scoping Review

BACKGROUND

mHealth applications provide health practitioners with platforms that enable disease management, facilitate drug adherence, facilitate drug adherence, speed up diagnosis, monitor outbreaks, take and transfer medical images, and provide advice. Many developing economies are investing more in mobile telecommunication infrastructure than in road transport and electric power generation. Despite this, mHealth has not seen widespread adoption by healthcare workers in the developing world. This study reports a scoping review of factors that impact the adoption of mHealth by healthcare workers in the developing world, and based on these findings, a framework is developed for enhancing mHealth adoption by healthcare workers in the developing world.

METHODS

A structured literature search was performed using PubMed and Scopus, supplemented by hand searching. The searches were restricted to articles in English during the period January 2009 to December 2019 and relevant to the developing world that addressed: mobile phone use by healthcare workers and identified factors impacting the adoption of mHealth implementations. All authors reviewed selected papers, with final inclusion by consensus. Data abstraction was performed by all authors. The results were used to develop the conceptual framework using inductive iterative content analysis.

RESULTS AND DISCUSSION

Of 919 articles, 181 met the inclusion criteria and, following a review of full papers, 85 reported factors that impact (promote or impede) healthcare worker adoption of mHealth applications. These factors were categorised into 18 themes and, after continued iterative review and discussion were reduced to 7 primary categories (engagement/funding, infrastructure, training/technical support, healthcare workers' mobile-cost/ownership, system utility, motivation/staffing, patients' mobile-cost/ownership), with 17 sub-categories. These were used to design the proposed framework.

CONCLUSIONS

Successful adoption of mHealth by healthcare workers in the developing world will depend on addressing the factors identified in the proposed framework. They must be assessed in each specific setting prior to mHealth implementation. Application of the proposed framework will help shape future policy and practice of mHealth implementation in the developing world and increase adoption by health workers.

Perspectives and Experiences of Patient-Led Melanoma Surveillance Using Digital Technologies From Clinicians Involved in the MEL-SELF Pilot Randomized Controlled Trial: Qualitative Interview Study

BACKGROUND

The growing number of melanoma patients who need long-term surveillance increasingly exceeds the capacity of the dermatology workforce, particularly outside of metropolitan areas. Digital technologies that enable patients to perform skin self-examination and send dermoscopic images of lesions of concern to a dermatologist (mobile teledermoscopy) are a potential solution. If these technologies and the remote delivery of melanoma surveillance are to be incorporated into routine clinical practice, they need to be accepted by clinicians providing melanoma care, such as dermatologists and general practitioners (GPs).

OBJECTIVE

This study aimed to explore perceptions of potential benefits and harms of mobile teledermoscopy, as well as experiences with this technology, among clinicians participating in a pilot randomized controlled trial (RCT) of patient-led melanoma surveillance.

METHODS

This qualitative study was nested within a pilot RCT conducted at dermatologist and skin specialist GP-led melanoma clinics in New South Wales, Australia. We conducted semistructured interviews with 8 of the total 11 clinicians who were involved in the trial, including 4 dermatologists (3 provided teledermatology, 2 were treating clinicians), 1 surgical oncologist, and 3 GPs with qualifications in skin cancer screening (the remaining 3 GPs declined an interview). Thematic analysis was used to analyze the data with reference to the concepts of "medical overuse" and "high-value care."

RESULTS

Clinicians identified several potential benefits, including increased access to dermatology services, earlier detection of melanomas, reassurance for patients between scheduled visits, and a reduction in unnecessary clinic visits. However, they also identified some potential concerns regarding the use of the technology and remote monitoring that could result in diagnostic uncertainty. These included poor image quality, difficulty making assessments from a 2D digital image (even if good quality), insufficient clinical history provided, and concern that suspicious lesions may have been missed by the patient. Clinicians thought that uncertainty arising from these concerns, together with perceived potential medicolegal consequences from missing a diagnosis, might lead to increases in unnecessary clinic visits and procedures. Strategies suggested for achieving high-value care included managing clinical uncertainty to decrease the potential for medical overuse and ensuring optimal placement of patient-led teledermoscopy within existing clinical care pathways to increase the potential for benefits.

CONCLUSIONS

Clinicians were enthusiastic about the potential and experienced benefits of mobile teledermoscopy; however, managing clinical uncertainty will be necessary to achieve these benefits in clinical care outside of trial contexts and minimize potential harms from medical overuse.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12616001716459; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371865.

Guidance for the Interpretation of Continual Cuffless Blood Pressure Data for the Diagnosis and Management of Hypertension

Hypertension remains the leading risk factor for death worldwide. Despite its prevalence, success of blood pressure (BP) management efforts remains elusive, and part of the difficulty lies in the tool still used to diagnose, measure, and treat hypertension: the sphygmomanometer introduced by Samuel Siegfried Karl von Basch in 1867. In recent years, there has been an explosion of devices attempting to provide estimates of BP without a cuff, overcoming many limitations of cuff-based BP monitors. Unfortunately, the differences in underlying technologies between traditional BP cuffs and newer cuffless devices, as well as hesitancy of changing a well-implemented standard, still generate understandable skepticism about and reluctance to adopt cuffless BP monitors in clinical practice. This guidance document aims to navigate the scientific and medical communities through the types of cuffless devices and present examples of robust BP data collection which are better representations of a person's true BP. It highlights the differences between data collected by cuffless and traditional cuff-based devices and provides an initial framework of interpretation of the new cuffless datasets using, as an example, a CE-marked continual cuffless BP device (Aktiia BP Monitor, Aktiia, Switzerland). Demonstration of novel BP metrics, which have the potential to change the paradigm of hypertension diagnosis and treatment, are now possible for the first time with cuffless BP monitors that provide continual readings over long periods. Widespread adoption of continual cuffless BP monitors in healthcare will require a collaborative and thoughtful process, acknowledging that the transition from a legacy to a novel medical technology will be slow. Finally, this guidance concludes with a call to action to international scientific and expert associations to include cuffless BP monitors in original scientific research and in future versions of guidelines and standards.

Sociotechnical Factors Affecting Patients' Adoption of Mobile Health Tools: Systematic Literature Review and Narrative Synthesis

Background

Mobile health (mHealth) tools have emerged as a promising health care technology that may contribute to cost savings, better access to care, and enhanced clinical outcomes; however, it is important to ensure their acceptance and adoption to harness this potential. Patient adoption has been recognized as a key challenge that requires further exploration.

Objective

The aim of this review was to systematically investigate the literature to understand the factors affecting patients’ adoption of mHealth tools by considering sociotechnical factors (from technical, social, and health perspectives).

Methods

A structured search was completed following the participants, intervention, comparators, and outcomes framework. We searched the MEDLINE, PubMed, Cochrane Library, and SAGE databases for studies published between January 2011 and July 2021 in the English language, yielding 5873 results, of which 147 studies met the inclusion criteria. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and the Cochrane Handbook were followed to ensure a systematic process. Extracted data were analyzed using NVivo (QSR International), with thematic analysis and narrative synthesis of emergent themes.

Results

The technical factors affecting patients’ adoption of mHealth tools were categorized into six key themes, which in turn were divided into 20 subthemes: usefulness, ease of use, data-related, monetary factors, technical issues, and user experience. Health-related factors were categorized into six key themes: the disease or health condition, the care team’s role, health consciousness and literacy, health behavior, relation to other therapies, integration into patient journey, and the patients’ insurance status. Social and personal factors were divided into three key clusters: demographic factors, personal characteristics, and social and cultural aspects; these were divided into 19 subthemes, highlighting the importance of considering these factors when addressing potential barriers to mHealth adoption and how to overcome them.

Conclusions

This review builds on the growing body of research that investigates patients’ adoption of mHealth services and highlights the complexity of the factors affecting adoption, including personal, social, technical, organizational, and health care aspects. We recommend a more patient-centered approach by ensuring the tools’ fit into the overall patient journey and treatment plan, emphasizing inclusive design, and warranting comprehensive patient education and support. Moreover, empowering and mobilizing clinicians and care teams, addressing ethical data management issues, and focusing on health care policies may facilitate adoption.

Ranked determinants of telemedicine diabetic retinopathy screening performance in the United States primary care safety-net setting: an exploratory CART analysis

Background

Diabetic retinopathy (DR) is a leading cause of blindness worldwide, despite easy detection and effective treatment. Annual screening rates in the USA remain low, especially for the disadvantaged, which telemedicine-based DR screening (TDRS) during routine primary care has been shown to improve. Screening rates from such programs have varied, however, pointing to inconsistent implementation and unaddressed barriers. This work seeks to identify and prioritize modifiable barriers for targeted intervention.

Methods

In this final phase of an exploratory mixed-methods study, we developed, validated, and administered a 62-item survey to multilevel stakeholders involved with TDRS in primary care safety-net clinics. Survey items were aligned with previously identified determinants of clinic-level screening and mapped to the Consolidated Framework for Implementation Research (CFIR). Classification and Regression Tree (CART) analyses were used to identify and rank independent variables predictive of individual-level TDRS screening performance.

Results

Overall, 133 of the 341 invited professionals responded (39%), representing 20 safety-net clinics across 6 clinical systems. Respondents were predominately non-Hispanic White (77%), female (94%), and between 31 and 65 years of age (79%). Satisfaction with TDRS was high despite low self-reported screening rates. The most important screening determinants were: provider reinforcement of TDRS importance; explicit instructions by providers to staff; effective reminders; standing orders; high relative priority among routine diabetic measures; established TDRS workflows; performance feedback; effective TDRS champions; and leadership support.

Conclusions

In this survey of stakeholders involved with TDRS in safety-net clinics, screening was low despite high satisfaction with the intervention. The best predictors of screening performance mapped to the CFIR constructs Leadership Engagement, Compatibility, Goals & Feedback, Relative Priority, Champions, and Available Resources. These findings facilitate the prioritization of implementation strategies targeting determinants of TDRS performance, potentially increasing its public health impact.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07915-5.

Papers please: Factors affecting national and international COVID-19 immunity and vaccination passport uptake as determined by representative national surveys

BACKGROUND

In response to the COVID-19 pandemic, countries are introducing digital passports that allow citizens to return to normal activities if they were previously infected with (immunity passport) or vaccinated against (vaccination passport) SARS-CoV-2. To be effective, policy decision makers must know whether these passports will be widely accepted by the public, and under what conditions? This study focuses attention on immunity passports, as these may prove useful in countries both with and without an existing COVID-19 vaccination program, however, our general findings also extend to vaccination passports.

OBJECTIVE

We aimed to assess attitudes towards the introduction of immunity passports in six countries, and determine what social, personal and contextual factors predicted their support.

METHODS

We collected 13,678 participants through online representative sampling across six countries - Australia, Japan, Taiwan, Germany, Spain, and the United Kingdom - during April to May of the 2020 COVID-19 pandemic, and assessed attitudes and support for the introduction of immunity passports.

RESULTS

Immunity passport support was moderate-to-low, being highest in Germany (51%; 775 of 1507 participants) and the United Kingdom (51%; 759 of 1484), followed by Taiwan (47%; 2841 of 5989), Australia (46%; 963 of 2086) and Spain (46%; 693 of 1491), and lowest in Japan (22%; 241 of 1081). Bayesian generalized linear mixed-effects modelling assessed predictive factors for immunity passport support across countries. International results showed neoliberal world views (odds ratio, OR = 1.17, CI[1.13:1.22]), personal concern (OR = 1.07, CI[1:1.16]) and perceived virus severity (OR = 1.07, CI[1.01:1.14]), the fairness of immunity passports (OR = 2.51, CI[2.36:2.66]), liking immunity passports (OR = 2.77, CI[2.61:2.94]), and a willingness to become infected to gain an immunity passport (OR = 1.6, CI[1.51:1.68]), were all predictive factors of immunity passport support. By contrast, gender (woman; OR = 0.9, CI[0.82:0.98]), immunity passport concern (OR = 0.61, CI[0.57:0.65]), and risk of harm to society (OR = 0.71, CI[0.67:0.76]) predicted a decrease in support for immunity passports. Minor differences in predictive factors were found between countries and results were modelled separately to provide national accounts of these data.

CONCLUSIONS

Our research suggests that support for immunity passports is predicted by the personal benefits and societal risks they confer. These findings generalized across six countries and may also prove informative for the introduction of vaccination passports, helping policy-makers to introduce effective COVID-19 passport policies in these six countries and around the world.

CLINICALTRIAL

Usability Testing and Technology Acceptance of an mHealth App at the Point of Care During Simulated Pediatric In- and Out-of-Hospital Cardiopulmonary Resuscitations: Study Nested Within 2 Multicenter Randomized Controlled Trials

BACKGROUND

Mobile apps are increasingly being used in various domains of medicine. Few are evidence-based, and their benefits can only be achieved if end users intend to adopt and use them. To date, only a small fraction of mobile apps have published data on their field usability and end user acceptance results, especially in emergency medicine.

OBJECTIVE

This study aims to determine the usability and acceptance of an evidence-based mobile app while safely preparing emergency drugs at the point of care during pediatric in- and out-of-hospital cardiopulmonary resuscitations by frontline caregivers.

METHODS

In 2 multicenter randomized controlled parent trials conducted at 6 pediatric emergency departments from March 1 to December 31, 2017, and 14 emergency medical services from September 3, 2019, to January 21, 2020, the usability and technology acceptance of the PedAMINES (Pediatric Accurate Medication in Emergency Situations) app were evaluated among skilled pediatric emergency nurses and advanced paramedics when preparing continuous infusions of vasoactive drugs and direct intravenous emergency drugs at pediatric dosages during standardized, simulation-based, pediatric in- and out-of-hospital cardiac arrest scenarios, respectively. Usability was measured using the 10-item System Usability Scale. A 26-item technology acceptance self-administered survey (5-point Likert-type scales), adapted from the Unified Theory of Acceptance and Use of Technology model, was used to measure app acceptance and intention to use.

RESULTS

All 100% (128/128) of nurses (crossover trial) and 49.3% (74/150) of paramedics (parallel trial) were assigned to the mobile app. Mean total scores on the System Usability Scale were excellent and reached 89.5 (SD 8.8; 95% CI 88.0-91.1) for nurses and 89.7 (SD 8.7; 95% CI 87.7-91.7) for paramedics. Acceptance of the technology was very good and rated on average >4.5/5 for 5 of the 8 independent constructs evaluated. Only the image construct scored between 3.2 and 3.5 by both participant populations.

CONCLUSIONS

The results provide evidence that dedicated mobile apps can be easy to use and highly accepted at the point of care during in- and out-of-hospital cardiopulmonary resuscitations by frontline emergency caregivers. These findings can contribute to the implementation and valorization of studies aimed at evaluating the usability and acceptance of mobile apps in the field by caregivers, even in critical situations.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03021122; https://clinicaltrials.gov/ct2/show/NCT03021122. ClinicalTrials.gov NCT03921346; https://clinicaltrials.gov/ct2/show/NCT03921346.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13063-019-3726-4.

Frameworks for implementation, uptake and use of digital health interventions in ethnic minority populations: a scoping review using cardiometabolic disease as a case study. (Preprint)

Background

Digital health interventions have become increasingly common across health care, both before and during the COVID-19 pandemic. Health inequalities, particularly with respect to ethnicity, may not be considered in frameworks that address the implementation of digital health interventions. We considered frameworks to include any models, theories, or taxonomies that describe or predict implementation, uptake, and use of digital health interventions.

Objective

We aimed to assess how health inequalities are addressed in frameworks relevant to the implementation, uptake, and use of digital health interventions; health and ethnic inequalities; and interventions for cardiometabolic disease.

Methods

SCOPUS, PubMed, EMBASE, Google Scholar, and gray literature were searched to identify papers on frameworks relevant to the implementation, uptake, and use of digital health interventions; ethnically or culturally diverse populations and health inequalities; and interventions for cardiometabolic disease. We assessed the extent to which frameworks address health inequalities, specifically ethnic inequalities; explored how they were addressed; and developed recommendations for good practice.

Results

Of 58 relevant papers, 22 (38%) included frameworks that referred to health inequalities. Inequalities were conceptualized as society-level, system-level, intervention-level, and individual. Only 5 frameworks considered all levels. Three frameworks considered how digital health interventions might interact with or exacerbate existing health inequalities, and 3 considered the process of health technology implementation, uptake, and use and suggested opportunities to improve equity in digital health. When ethnicity was considered, it was often within the broader concepts of social determinants of health. Only 3 frameworks explicitly addressed ethnicity: one focused on culturally tailoring digital health interventions, and 2 were applied to management of cardiometabolic disease.

Conclusions

Existing frameworks evaluate implementation, uptake, and use of digital health interventions, but to consider factors related to ethnicity, it is necessary to look across frameworks. We have developed a visual guide of the key constructs across the 4 potential levels of action for digital health inequalities, which can be used to support future research and inform digital health policies.

Technology-supported models of nutrition care: Perspectives of health service providers

Objective

To determine the perspectives to the adoption, scale-up, sustainability, and spread of technology-supported models of nutrition care, in hospital and ambulatory care settings.

Methods

Thirty-one health service providers participated in individual semi-structured interviews from a tertiary health service in Queensland, Australia. The Non-adoption, Abandonment, and challenges to the Scale up, Spread and Sustainability (NASSS) framework, designed to evaluate technology-supported models’ success, informed the qualitative design.

Results

Key findings were that technology-supported models of care could benefit many chronic condition patient groups; dietitians are well suited to adopting this technology: and the value proposition in creating efficiency gains in the health service. However, challenges of transitioning and sustainability were identified. Perceived enablers for technology supported models of care included: previous intentions for technology supported models of care prior to the 2019 novel coronavirus pandemic; opportunity for clinicians to complete higher valued tasks; and integration of technology systems and assisted staff roles. Perceived barriers included: suitability for patients is dependent on experience and ability to use technology, varied confidence by clinicians when conducting clinical assessments; high investment required for set up and ongoing maintenance; and patients desire for adopting face-to-face care over technology. Health service providers perceived that embedding and adapting such models requires maintenance of high-quality service and continued research.

Conclusions

Health service providers recognize adopting, scaling, and sustaining technology-supported models of nutrition care benefits patients, clinicians, and health services in general. Robust clinical trials and health service evaluations of technology-supported models of care, across practice settings are now needed.

There's an app for that, but nobody's using it: Insights on improving patient access and adherence to digital therapeutics in Germany

Background

Mobile health applications and their subset digital therapeutics—defined as evidence-based software interventions to prevent, manage, or treat a medical condition—offer great potential to improve patient care. However, such solutions often struggle to reach widespread adoption.

Objective

This study seeks to explore healthcare stakeholders’ roles and potential for fostering patient access and adherence to evidence-based digital therapeutics and thereby improve health outcomes from the perspective of digital therapeutics developers and distributors.

Methods

Semi-structured qualitative and semiquantitative interviews were conducted with 19 experts from developers and distributors of digital therapeutics in Germany to discuss their perceived relevance of different healthcare stakeholders and strategies in promoting patient access and adherence to digital therapeutics.

Results

Healthcare professionals were found to have the greatest potential to promote both access and patient adherence to digital therapeutics, followed by health insurers, pharmaceutical companies, and patients themselves. In terms of patient access, healthcare professionals have potential due to their ability to prescribe digital therapeutics. Other stakeholders’ potential stems from their capacity to influence healthcare professionals prescription decision. In terms of patient adherence, only healthcare professionals are of high relevance by onboarding patients and monitoring digital therapeutics use. Most healthcare stakeholders currently do not fully leverage their potential. Further educating healthcare professionals and simplifying processes for them, empowering patients to seek treatment with digital therapeutics, and designing digital therapeutics’ product features for better adherence can help improve patient access and adherence.

Conclusions

Established healthcare stakeholders and digital therapeutics developers both need to take action to improve patient access and adherence to digital therapeutics. Several macro-level changes can support these efforts, including broader information dissemination, improved financial incentives, simplified prescription and activation processes, and a wider adoption of blended care and pay-for-performance payment models.

The development of an instrument to predict patients’ adoption of mHealth in the developing world

Introduction:

Method:

Results:

Conclusion:

Continuous Remote Patient Monitoring: Evaluation of the Heart Failure Cascade Soft Launch

OBJECTIVE

We report on our experience of deploying a continuous remote patient monitoring (CRPM) study soft launch with structured cascading and escalation pathways on heart failure (HF) patients post-discharge. The lessons learned from the soft launch are used to modify and fine-tune the workflow process and study protocol.

METHODS

This soft launch was conducted at NorthShore University HealthSystem's Evanston Hospital from December 2020 to March 2021. Patients were provided with non-invasive wearable biosensors that continuously collect ambulatory physiological data, and a study phone that collects patient-reported outcomes. The physiological data are analyzed by machine learning algorithms, potentially identifying physiological perturbation in HF patients. Alerts from this algorithm may be cascaded with other patient status data to inform home health nurses' (HHNs') management via a structured protocol. HHNs review the monitoring platform daily. If the patient's status meets specific criteria, HHNs perform assessments and escalate patient cases to the HF team for further guidance on early intervention.

RESULTS

We enrolled five patients into the soft launch. Four participants adhered to study activities. Two out of five patients were readmitted, one due to HF, one due to infection. Observed miscommunication and protocol gaps were noted for protocol amendment. The study team adopted an organizational development method from change management theory to reconfigure the study protocol.

CONCLUSION

We sought to automate the monitoring aspects of post-discharge care by aligning a new technology that generates streaming data from a wearable device with a complex, multi-provider workflow into a novel protocol using iterative design, implementation, and evaluation methods to monitor post-discharge HF patients. CRPM with structured escalation and telemonitoring protocol shows potential to maintain patients in their home environment and reduce HF-related readmissions. Our results suggest that further education to engage and empower frontline workers using advanced technology is essential to scale up the approach.

Physicians' Attitudes Toward Prescribable mHealth Apps and Implications for Adoption in Germany: Mixed Methods Study

Background

In October 2020, Germany became the first country, worldwide, to approve certain mobile health (mHealth) apps, referred to as DiGA (Digitale Gesundheitsanwendungen, in German, meaning digital health applications), for prescription with costs covered by standard statutory health insurance. Yet, this option has only been used to a limited extent so far.

Objective

The aim of this study was to investigate physicians’ and psychotherapists’ current attitudes toward mHealth apps, barriers to adoption, and potential remedies.

Methods

We conducted a two-stage sequential mixed methods study. In phase one, semistructured interviews were conducted with physicians and psychotherapists for questionnaire design. In phase two, an online survey was conducted among general practitioners, physicians, and psychotherapists.

Results

A total of 1308 survey responses by mostly outpatient-care general practitioners, physicians, and psychotherapists from across Germany who could prescribe DiGA were recorded, making this the largest study on mHealth prescriptions to date. A total of 62.1% (807/1299) of respondents supported the opportunity to prescribe DiGA. Improved adherence (997/1294, 77.0%), health literacy (842/1294, 65.1%), and disease management (783/1294, 60.5%) were most frequently seen as benefits of DiGA. However, only 30.3% (393/1299) of respondents planned to prescribe DiGA, varying greatly by medical specialty. Professionals are still facing substantial barriers, such as insufficient information (1135/1295, 87.6%), reimbursement for DiGA-related medical services (716/1299, 55.1%), medical evidence (712/1298, 54.9%), legal uncertainties (680/1299, 52.3%), and technological uncertainties (658/1299, 50.7%). To support professionals who are unsure of prescribing DiGA, extended information campaigns (1104/1297, 85.1%) as well as recommendations from medical associations (1041/1297, 80.3%) and medical colleagues (1024/1297, 79.0%) were seen as the most impactful remedies.

Conclusions

To realize the benefits from DiGA through increased adoption, additional information sharing about DiGA from trusted bodies, reimbursement for DiGA-related medical services, and further medical evidence are recommended.

Adoption of Pharmacogenomic Testing: A Marketing Perspective

Pharmacogenomics is becoming an important part of clinical practice and it is considered one of the basic pillars of personalised medicine. However, the rate of pharmacogenomics adoption is still low in many healthcare systems, especially in low- or middle-income countries. The low level of awareness of healthcare specialists could be a potential reason due to which pharmacogenomics application is still in a premature stage but there are several other barriers that impede the aforementioned process, including the lack of the proper promotion of pharmacogenomic testing among interested stakeholders, such as healthcare professionals and biomedical scientists. In this study, we outline the available marketing theories and innovation that are applied to personalized medicine interventions that would catalyze the adoption of pharmacogenomic testing services in clinical practice. We also present the current ethical and legal framework about genomic data and propose ways to tackle the main concerns mentioned in the literature and to improve the marketing perspective of PGx.

Context and Complexity in Telemedicine Evaluation: Work Domain Analysis in a Surgical Setting

Many promising telemedicine innovations fail to be accepted and used over time, and there are longstanding questions about how to best evaluate telemedicine services and other health information technologies. In response to these challenges, there is a growing interest in how to take the sociotechnical complexity of health care into account during design, implementation, and evaluation. This paper discusses the methodological implications of this complexity and how the sociotechnical context holds the key to understanding the effects and outcomes of telemedicine. Examples from a work domain analysis of a surgical setting, where a telemedicine service for remote surgical consultation was to be introduced, are used to show how abstracted functional modeling can provide a structured and rigorous means to analyze and represent the implementation context in complex health care settings.

Challenges of Implementing an mHealth Application for Personalized Physical Activity Counselling in Primary Health Care: A Qualitative Study

Introduction

A mobile health (mHealth) technology has the potential to facilitate personalized physical activity (PA) counselling. We aimed to explore the feasibility and challenges of implementing a newly developed mHealth application (PAC app) for personalized PA counselling.

Material and Methods

A qualitative design employed a descriptive phenomenology approach. Data were collected through focus group discussions (FGDs) with primary health care (PHC) providers and were analyzed using a deductive thematic approach.

Results

A total of 16 participants participated in four FGDs. Four major themes were found: application for personalized PA counselling, barriers to the use of the application by providers, patient involvement, and impact on PHC services.

Discussion

The results showed that the new mHealth application can potentially facilitate PA counselling. However, its use in PHC settings requires an understanding of the context of service delivery; the challenges faced by providers and patients and effects on services must be considered.

Conclusion

Future research should focus on the long-term use of PAC app and its impact on behavioral and health outcomes.

Experience Sampling and Programmed Intervention Method and System for Planning, Authoring, and Deploying Mobile Health Interventions: Design and Case Reports

BACKGROUND

Health professionals initiating mobile health (mHealth) interventions may choose to adapt apps designed for other activities (eg, peer-to-peer communication) or to employ purpose-built apps specialized in the required intervention, or to exploit apps based on methods such as the experience sampling method (ESM). An alternative approach for professionals would be to create their own apps. While ESM-based methods offer important guidance, current systems do not expose their design at a level that promotes replicating, specializing, or extending their contributions. Thus, a twofold solution is required: a method that directs specialists in planning intervention programs themselves, and a model that guides specialists in adopting existing solutions and advises software developers on building new ones.

OBJECTIVE

The main objectives of this study are to design the Experience Sampling and Programmed Intervention Method (ESPIM), formulated toward supporting specialists in deploying mHealth interventions, and the ESPIM model, which guides health specialists in adopting existing solutions and advises software developers on how to build new ones. Another goal is to conceive and implement a software platform allowing specialists to be users who actually plan, create, and deploy interventions (ESPIM system).

METHODS

We conducted the design and evaluation of the ESPIM method and model alongside a software system comprising integrated web and mobile apps. A participatory design approach with stakeholders included early software prototype, predesign interviews with 12 health specialists, iterative design sustained by the software as an instance of the method's conceptual model, support to 8 real case studies, and postdesign interviews.

RESULTS

The ESPIM comprises (1) a list of requirements for mHealth experience sampling and intervention-based methods and systems, (2) a 4-dimension planning framework, (3) a 7-step-based process, and (4) an ontology-based conceptual model. The ESPIM system encompasses web and mobile apps. Eight long-term case studies, involving professionals in psychology, gerontology, computer science, speech therapy, and occupational therapy, show that the method allowed specialists to be actual users who plan, create, and deploy interventions via the associated system. Specialists' target users were parents of children diagnosed with autism spectrum disorder, older persons, graduate and undergraduate students, children (age 8-12), and caregivers of older persons. The specialists reported being able to create and conduct their own studies without modifying their original design. A qualitative evaluation of the ontology-based conceptual model showed its compliance to the functional requirements elicited.

CONCLUSIONS

The ESPIM method succeeds in supporting specialists in planning, authoring, and deploying mobile-based intervention programs when employed via a software system designed and implemented according to its conceptual model. The ESPIM ontology-based conceptual model exposes the design of systems involving active or passive sampling interventions. Such exposure supports the evaluation, implementation, adaptation, or extension of new or existing systems.

Digital Monitoring and Management of Patients With Advanced or Metastatic Non-Small Cell Lung Cancer Treated With Cancer Immunotherapy and Its Impact on Quality of Clinical Care: Interview and Survey Study Among Health Care Professionals and Patients

Background

Cancer immunotherapy (CIT), as a monotherapy or in combination with chemotherapy, has been shown to extend overall survival in patients with locally advanced or metastatic non-small cell lung cancer (NSCLC). However, patients experience treatment-related symptoms that they are required to recall between hospital visits. Digital patient monitoring and management (DPMM) tools may improve clinical practice by allowing real-time symptom reporting.

Objective

This proof-of-concept pilot study assessed patient and health care professional (HCP) adoption of our DPMM tool, which was designed specifically for patients with advanced or metastatic NSCLC treated with CIT, and the tool’s impact on clinical care.

Methods

Four advisory boards were assembled in order to co-develop a drug- and indication-specific CIT (CIT+) module, based on a generic CIT DPMM tool from Kaiku Health, Helsinki, Finland. A total of 45 patients treated with second-line single-agent CIT (ie, atezolizumab or otherwise) for advanced or metastatic NSCLC, as well as HCPs, whose exact number was decided by the clinics, were recruited from 10 clinics in Germany, Finland, and Switzerland between February and May 2019. All clinics were provided with the Kaiku Health generic CIT DPMM tool, including our CIT+ module. Data on user experience, overall satisfaction, and impact of the tool on clinical practice were collected using anonymized surveys—answers ranged from 1 (low agreement) to 5 (high agreement)—and HCP interviews; surveys and interviews consisted of closed-ended Likert scales and open-ended questions, respectively. The first survey was conducted after 2 months of DPMM use, and a second survey and HCP interviews were conducted at study end (ie, after ≥3 months of DPMM use); only a subgroup of HCPs from each clinic responded to the surveys and interviews. Survey data were analyzed quantitatively; interviews were recorded, transcribed verbatim, and translated into English, where applicable, for coding and qualitative thematic analysis.

Results

Among interim survey respondents (N=51: 13 [25%] nurses, 11 [22%] physicians, and 27 [53%] patients), mean rankings of the tool’s seven usability attributes ranged from 3.2 to 4.4 (nurses), 3.7 to 4.5 (physicians), and 3.7 to 4.2 (patients). At the end-of-study survey (N=48: 19 [40%] nurses, 8 [17%] physicians, and 21 [44%] patients), most respondents agreed that the tool facilitated more efficient and focused discussions between patients and HCPs (nurses and patients: mean rating 4.2, SD 0.8; physicians: mean rating 4.4, SD 0.8) and allowed HCPs to tailor discussions with patients (mean rating 4.35, SD 0.65). The standalone tool was well integrated into HCP daily clinical workflow (mean rating 3.80, SD 0.75), enabled workflow optimization between physicians and nurses (mean rating 3.75, SD 0.80), and saved time by decreasing phone consultations (mean rating 3.75, SD 1.00) and patient visits (mean rating 3.45, SD 1.20). Workload was the most common challenge of tool use among respondents (12/19, 63%).

Conclusions

Our results demonstrate high user satisfaction and acceptance of DPMM tools by HCPs and patients, and highlight the improvements to clinical care in patients with advanced or metastatic NSCLC treated with CIT monotherapy. However, further integration of the tool into the clinical information technology data flow is required. Future studies or registries using our DPMM tool may provide insights into significant effects on patient quality of life or health-economic benefits.

Factors Impacting Clinicians' Adoption of a Clinical Photo Documentation App and its Implications for Clinical Workflows and Quality of Care: Qualitative Case Study

BACKGROUND

Mobile health (mHealth) tools have shown promise in clinical photo and wound documentation for their potential to improve workflows, expand access to care, and improve the quality of patient care. However, some barriers to adoption persist.

OBJECTIVE

This study aims to understand the social, organizational, and technical factors affecting clinicians' adoption of a clinical photo documentation mHealth app and its implications for clinical workflows and quality of care.

METHODS

A qualitative case study of a clinical photo and wound documentation app called imitoCam was conducted. The data were collected through 20 in-depth interviews with mHealth providers, clinicians, and medical informatics experts from 8 clinics and hospitals in Switzerland and Germany.

RESULTS

According to the study participants, the use of mHealth in clinical photo and wound documentation provides numerous benefits such as time-saving and efficacy, better patient safety and quality of care, enhanced data security and validation, and better accessibility. The clinical workflow may also improve when the app is a good fit, resulting in better collaboration and transparency, streamlined daily work, clinician empowerment, and improved quality of care. The findings included important factors that may contribute to or hinder adoption. Factors may be related to the material nature of the tool, such as the perceived usefulness, ease of use, interoperability, cost, or security of the app, or social aspects such as personal experience, attitudes, awareness, or culture. Organizational and policy barriers include the available clinical practice infrastructure, workload and resources, the complexity of decision making, training, and ambiguity or lack of regulations. User engagement in the development and implementation process is a vital contributor to the successful adoption of mHealth apps.

CONCLUSIONS

The promising potential of mHealth in clinical photo and wound documentation is clear and may enhance clinical workflow and quality of care; however, the factors affecting adoption go beyond the technical features of the tool itself to embrace significant social and organizational elements. Technology providers, clinicians, and decision makers should work together to carefully address any barriers to improve adoption and harness the potential of these tools.