A framework for the evaluation of Internet-based diabetes management

Health Information Prescription System For Non Communicable Diseases: A Systematic Review And Thematic Analysis

Objective ― Prescribing health information is very important to empower informed patients. The goal of present study is to recognize challenges for developing health information prescription on non-communicable diseases. Material and Methods ― Six data bases related to health information prescription were investigated. They included Web of Science, Scopus, PubMed, Google Scholar, Ovid and EMBASE. The investigated studies were published from 2000 to 2019. The language of the articles was English and the access to full text was one of the inclusion criteria. The research was evaluated by Prisma checklist and critical apprising. Different dimensions of health Information prescription system were recognized by thematic analysis. Results ― 54 studies were recognized based on the inclusion criteria. The results showed that there were three main concepts related to primary dimensions of the system in designing health information prescription system: determination of system functional goals, recognition of implementation barriers and recognition of developmental sub-structures. There were 16 subcategories including primary goals for accessibility, the concerns related to patients information confidentiality, individual differences and interests and personalizing the process of information prescription, the lack of integrity in health Information system for providing pattern of health Information system related to diabetic patients. Conclusion ― The goals, implementing barriers and functional substructures of health information prescription system should be recognized in order to improve self-care behaviors of diabetic patients in clinic. It is recommended that the future investigations focus on research gaps in personalizing health information prescription and integration of health information prescription process in health care system.

What Do Patients Talk About? A Qualitative Analysis of Online Chat Sessions with Health Care Specialists During a "Virtual" Cardiac Rehabilitation Program

INTRODUCTION

Cardiac rehabilitation programs (CRPs) are effective at reducing cardiovascular disease (CVD) risk, yet attendance in these programs remains low due to geographic constraints. In a previously conducted randomized trial we demonstrated that a virtual CRP (vCRP) delivered over the Internet reduced risk for CVD. The current investigation has reviewed the online chat sessions between participants and healthcare providers (HCP) to describe the content of discussions during the vCRP intervention.

MATERIALS AND METHODS

Participants were recruited from two geographically isolated areas in British Columbia, Canada without in-person CRP or a cardiologist serving the area. The vCRP, among other elements, included scheduled one-on-one chat sessions with a dietician, exercise specialist, and nurse to mimic standard CRP consultations. The chat sessions were reviewed for content and themes. Multiple chat sessions between participants and a single care provider were also analyzed to describe how chat content progressed through multiple sessions.

RESULTS

A total of 38 participants participated in the vCRP intervention. From the 122 chat sessions between participants and HCP during the vCRP, the main themes identified were Managing Health and Lifestyle, Continuity of Care, and Getting Care from a Distance. Within each theme, sub-themes were also identified.

CONCLUSIONS

The vCRP chat sessions fulfilled the role of face-to-face consultations with HCP that are standard in hospital-based CRP and addressed patient concerns, facilitating remote patient-provider interaction and covering topics on exercise, diet, and positive behavior changes to limit risk factors for future heart problems.

Are Malaysian Diabetic Patients Ready to Use The New Generation of Health Care Service Delivery? A Telehealth Interest Assessment

BACKGROUND

The idea of launching an internet-based self-management program for patients with diabetes led us to do a cross-sectional study to find out about the willingness, interest, equipment, and level of usage of computer and internet in a medium- to low-social class area and to find the feasibility of using e-telemonitoring systems for these patients.

METHODS

A total of 180 patients with type 2 diabetes participated in this study and fulfilled the self-administered questionnaire in Diabetes Clinic of Primary Medical Center of University Kebangsaan Malaysia Medical Centre; the response rate was 84%. We used the universal sampling method and assessed three groups of factors including sociodemographic, information and communication technology (ICT), willingness and interest, and disease factors.

RESULTS

Our results showed that 56% of the patients with diabetes were interested to use such programs; majority of the patients were Malay, and patients in the age group of 51-60 years formed the largest group. Majority of these patients studied up to secondary level of education. Age, education, income, and money spent for checkup were significantly associated with the interest of patients with diabetes to the internet-based programs. ICT-related factors such as computer ownership, computer knowledge, access to the internet, frequency of using the internet and reasons of internet usage had a positive effect on patients' interest.

CONCLUSION

Our results show that among low to intermediate social class of Malaysian patients with type 2 diabetes, more than 50% of them can and wanted to use the internet-based self-management programs. Furthermore, we also show that patients equipped with more ICT-related factors had more interest toward these programs. Therefore, we propose making ICT more affordable and integrating it into the health care system at primary care level and then extending it nationwide.

A Wide Spectrum of Axial Mesodermal Dysplasia Complex With Rhombencephalic Anomaly: A Case Report

Axial mesodermal dysplasia complex (AMDC) arises in variable combinations of craniocaudal anomalies such as musculoskeletal deformities, neuroschisis, or rhombencephalic developmental disorders. To the best of our knowledge, the co-existence of AMDC with associated musculoskeletal anomalies, medullary neuroschisis with mirror movements, and cranial nerve anomalies has not yet been reported. Here, we report the case of a 4-year-old boy whose clinical features were suggestive of Goldenhar syndrome and Poland syndrome with Sprengel deformity. Moreover, he showed mirror movements in his hands suspected of rhombencephalic malformation, and infranuclear-type facial nerve palsy of the left side of his face, the opposite side to the facial anomalies of Goldenhar syndrome. After conducting radiological studies, he was diagnosed with medullary neuroschisis without pontine malformations and Klippel-Feil syndrome with rib anomalies. Based on these findings, we propose that clinical AMDC can be accompanied by a wide variety of musculoskeletal defects and variable degrees of central nervous system malformations. Therefore, in addition to detailed physical and neurological examinations, imaging studies should be considered in AMDC.

Clinicians' perspectives on a Web-based system for routine outcome monitoring in old-age psychiatry in the Netherlands

BACKGROUND

In health care, the use of physical parameters to monitor physical disease progress is common. In mental health care, the periodic measurement of a client's functioning during treatment, or routine outcome monitoring, has recently become important. Online delivery of questionnaires has the potential to reduce clinicians' resistance to the implementation of routine outcome monitoring. Online delivery enables clinicians to receive results on a questionnaire in a graphic directly after data entry. This gives them insight into the progress of a client at a single glance.

OBJECTIVE

To explore clinicians' perspectives on a routine outcome monitoring procedure where questionnaires and feedback on scores were delivered online. Questionnaires could also be filled out on paper and then entered into the online system by a research assistant.

METHODS

In 2009 we sent an online survey, consisting of five yes-or-no questions and six open-ended questions, to all clinicians in the 14 mental health care organizations working with the routine outcome monitoring system in the Netherlands. Of the 172 clinicians contacted, 80 (47%) opened the link and 70 of these 80 (88%) clinicians completed the survey.

RESULTS

Clinicians seldom used the graphical feedback from the Web-based system, which indicates that direct feedback on scores did not enhance the implementation of routine outcome monitoring. Integration into the electronic patient record and more training on interpretation and implementation of feedback in daily practice were seen as the primary points for further improvement. It was mainly the availability of a research assistant that made the routine outcome monitoring procedure feasible.

CONCLUSIONS

Without a research assistant and training in the interpretation of outcomes, software programs alone cannot ensure effective implementation of monitoring activities in everyday practice.

Diagnostics, theragnostics, and the personal health server: fundamental milestones in technology with revolutionary changes in diabetic foot and wound care to come

Over the past generation, significant advances in care have led to reductions in amputation worldwide. However, it may be argued that the most potent advances in healing have been in organization of care. Technologies are now emerging that may allow further enhancements of organization and integration of care while also bringing in much needed bedside, chairside, and in-home diagnostics to identify key points in healing and potential early warning signs for recurrence. This article reviews what are believed to be 6 key areas of change over the next generation. These include portability, durability, automation, intelligence, ubiquity, and afford-ability, all yielding specific advances in wound diagnostics. The authors believe that devices will be organized into personal health servers in cloud-synchronized devices already existing in the home (eg, a scale), the clinic, and on (or in) the patient.

Usability evaluation of a web-based patient information system for individuals with severe mental health problems

AIM

This paper is a report of a study conducted to compare service users', nursing students' and Registered Nurses' evaluations of the usability of a patient education website intended for individuals with severe mental health problems.

BACKGROUND

There is an obvious need for reliable mental health information on the Internet. When evaluating the usability of Internet-based patient education methods, the opinions of all parties need to be ascertained.

METHODS

An explorative descriptive design was used. Twenty-one service users, 20 nursing students and 35 Registered Nurses were recruited for the study in 2003 and 2004. Data were collected using a self-developed questionnaire on the content, structure and visual appearance of the website.

RESULTS

Service users had positive attitudes towards computer and Internet use but they needed support when using the computer and Internet. According to the evaluations, the content, structure and visual appearance of the website were good and it could be adopted for clinical practise after minor revisions. There were some differences in the evaluations between participant groups. Nurses were the most critical group, and the service user group was the most satisfied, although they were less experienced with using both computers and the Internet.

CONCLUSION

It is especially important to include service users' evaluations at the early stages of the development process of Web-based patient education systems. It is possible to produce an information technology-based patient education system for individuals with severe mental health problems. Nurses working in psychiatric services need to pay more attention to supporting service users in computer and Internet use.

Assessing interest in an osteoporosis website: a survey among women eligible for osteoporosis screening

A survey was conducted to assess interest in an osteoporosis website. Two thirds of respondents indicated they would read about osteoporosis on a website, and half reported they might use the website more interactively. Women were receptive to the concept of web-based education and management of osteoporosis care.

INTRODUCTION

As Americans increasingly use the Internet as a source for health information, healthcare providers continue to develop disease management and education websites. Providence Health & Services conducted a survey among female patients eligible for osteoporosis screening to assess interest in a physician-prescribed osteoporosis website.

METHODS

In 2006, a self-administered survey designed to assess osteoporosis status, Internet use, and the likelihood of using an osteoporosis website for information and disease management was sent to 3,000 active female patients between the ages of 50 and 85 in the Portland, Oregon metropolitan area.

RESULTS

Among 778 respondents, 80% reported having access to the Internet, and 70% indicated they were likely to use the Internet for health-related information gathering. While 65% of respondents indicated they would be likely to read about osteoporosis on a dedicated website, only about half reported they might use the website for more interactive disease management activities such as scheduling appointments, receiving test results, or consulting with their physician. Both Internet access and interest in the osteoporosis website declined significantly with age.

CONCLUSIONS

These data suggest that middle-aged women are moderately receptive to the concept of web-based care for certain components of osteoporosis management and education.

Introducing telemonitoring for diabetic patients: development of a telemonitoring 'Health Effect and Readiness' Questionnaire

PURPOSE

Till now no validated instrument exists to measure the readiness and attitude of diabetic patients towards the use of telemonitoring. The purpose of the described study was to develop a Telemonitoring Attitude and Readiness Questionnaire and to check its validity and reliability.

METHODS

After performing in-depth interviews in two separate sessions, the Telemonitoring Attitude and Readiness Questionnaire was completed by a convenience sample of 138 patients with type 1 and type 2 diabetes to determine internal consistency. Test-retest reliability was further evaluated with a subsample of 21 patients.

RESULTS

Analysis supports the validity and reliability of the 13-item Telemonitoring Health Effect and Readiness Questionnaire (THERQ) with three subscales: Communication with peers or during holidays with a professional (Cronbach's alpha=0.84), telemonitoring health effect (Cronbach's alpha=0.87), and communication with a professional from home (Cronbach's alpha=0.88). Test-retest reliability is satisfactory (intraclass correlation coefficients between 0.58 and 0.92).

CONCLUSIONS

The results of this study provide preliminary evidence that the Telemonitoring Health Effect and Readiness Questionnaire is a valid and reliable instrument to measure the readiness and subjective feelings of health effect towards the use of telemonitoring. The THERQ could be used before the implementation of telemonitoring to check if diabetic patients are interested in the use of it but it could also be used in (randomized) controlled trials as the questions are put in such a way that also patients not (yet) using telemonitoring can answer the questions.

Asynchronous and synchronous teleconsultation for diabetes care: a systematic literature review

AIM

A systematic literature review, covering publications from 1994 to 2009, was carried out to determine the effects of teleconsultation regarding clinical, behavioral, and care coordination outcomes of diabetes care compared to usual care. Two types of teleconsultation were distinguished: (1) asynchronous teleconsultation for monitoring and delivering feedback via email and cell phone, automated messaging systems, or other equipment without face-to-face contact; and (2) synchronous teleconsultation that involves real-time, face-to-face contact (image and voice) via videoconferencing equipment (television, digital camera, webcam, videophone, etc.) to connect caregivers and one or more patients simultaneously, e.g., for the purpose of education.

METHODS

Electronic databases were searched for relevant publications about asynchronous and synchronous tele-consultation [Medline, Picarta, Psychinfo, ScienceDirect, Telemedicine Information Exchange, Institute for Scientific Information Web of Science, Google Scholar]. Reference lists of identified publications were hand searched. The contribution to diabetes care was examined for clinical outcomes [e.g., hemoglobin A1c (HbA1c), dietary values, blood pressure, quality of life], for behavioral outcomes (patient-caregiver interaction, self-care), and for care coordination outcomes (usability of technology, cost-effectiveness, transparency of guidelines, equity of access to care). Randomized controlled trials with HbA1c as an outcome were pooled using standard meta-analytical methods.

RESULTS

Of 2060 publications identified, 90 met inclusion criteria for electronic communication between (groups of) caregivers and patients with type 1 and 2 or gestational diabetes. Studies that evaluated teleconsultation not particularly aimed at diabetes were excluded, as were those that described interventions aimed solely at clinical improvements (e.g., HbA1c or lipid profiles). In 63 of 90 interventions, the interaction had an asynchronous teleconsultation character, in 18 cases interaction was synchronously (videoconferencing), and 9 involved a combination of synchronous with asynchronous interaction. Most of the reported improvements concerned clinical values (n = 49), self-care (n = 46), and satisfaction with technology (n = 43). A minority of studies demonstrated improvements in patient-caregiver interactions (n = 28) and cost reductions (n = 27). Only a few studies reported enhanced quality of life (n = 12), transparency of health care (n = 7), and improved equity in care delivery (n = 4). Asynchronous and synchronous applications appeared to differ in the type of contribution they made to diabetes care compared to usual care: asynchronous applications were more successful in improving clinical values and self-care, whereas synchronous applications led to relatively high usability of technology and cost reduction in terms of lower travel costs for both patients and care providers and reduced unscheduled visits compared to usual care. The combined applications (n = 9) scored best according to quality of life (22.2%). No differences between synchronous and asynchronous teleconsultation could be observed regarding the positive effect of technology on the quality of patient-provider interaction. Both types of applications resulted in intensified contact and increased frequency of transmission of clinical values with respect to usual care. Fifteen of the studies contained HbA1c data that permitted pooling. There was significant statistical heterogeneity among the pooled randomized controlled trials (chi(2) = 96.46, P < 0.001). The pooled reduction in HbA1c was not statically significant (weighted mean difference -0.10; 95% confidence interval -0.39 to 0.18).

CONCLUSION

The included studies suggest that both synchronous and asynchronous teleconsultations for diabetes care are feasible, cost-effective, and reliable. However, it should be noted that many of the included studies showed no significant differences between control (usual care) and intervention groups. This might be due to the diversity and lack of quality in study designs (e.g., inaccurate or incompletely reported sample size calculations). Future research needs quasi-experimental study designs and a holistic approach that focuses on multilevel determinants (clinical, behavioral, and care coordination) to promote self-care and proactive collaborations between health care professionals and patients to manage diabetes care. Also, a participatory design approach is needed in which target users are involved in the development of cost-effective and personalized interventions. Currently, too often technology is developed within the scope of the existing structures of the health care system. Including patients as part of the design team stimulates and enables designers to think differently, unconventionally, or from a new perspective, leading to applications that are better tailored to patients' needs.

The potential of the internet for alternative caring practices for health

The practices of health care in late modernity are informed by competing visions of the ideal human and the nature of care. Western societies typically characterise the ideal human as independent and self-reliant. The resultant welfare systems provide temporary havens away from the everyday, competitive spaces of capitalist societies, termed here the enclave model. Social scientists problematise this model on several grounds: the construction of pathologised and medicalised body forms; the neglect of caring practices that are gendered, invisible and primarily private; the de-politicisation of caring practices. Policy calls reject reference to care and its associations with dependency, make visible and value informal care work or invoke a caring citizenship as a policy goal not just a means. Into this field of contested notions of care enters a well-documented rise in access to, and consultation through, the internet in everyday lives for a vast range of issues. Health care encountered online reflects a similar range in form as that encountered offline and much that is innovative, whilst clearly of benefit, does nothing to challenge the existing dominance of the enclave model of social care. However, certain groups of sites create spaces through which participants can both express and extract caring relationships that are otherwise unforthcoming. The paper argues that these sites afford the potential to develop an alternative model of caring, to reframe questions of how to care about distant others and to demonstrate the centrality of caring relations to human life.

A virtual clinic for diabetes self-management: pilot study

Background

Internet-based interventions to assist in diabetes management have the potential to provide patients with the information and support they need to become effective self-managers.

Objective

To assess the feasibility, acceptability, and effectiveness of an Internet-based virtual clinic designed to facilitate self-management in patients who used insulin pumps to manage their diabetes.

Methods

For a period of 6 months, 17 patients joined the virtual clinic. The system allowed patients to communicate with health professionals, interact with peers and access information. HbA1c, quality of life, and self-efficacy were monitored at baseline and after 6 months. Questionnaires and qualitative interviews examined patient experiences.

Results

Participants found the virtual clinic easy to use and positively rated its design. Peer support was the most valued aspect and the discussion boards the most used component. All participants highly rated the virtual clinic in terms of improving communication with peers, but few agreed it had improved communication with health care professionals. No significant improvements in physiological and psychological measurements were found. Regarding HbA1c measurements, there was no significant difference found between the pre- and post-test results (P = .53). Mean ADDQoL scores at baseline were -2.1 (SD 1.1, range -3.4 to -0.5) compared to -2.0 (SD 1.2, range, -4.6 to -0.4) post-test (n = 12), (P = .62). Surprisingly, patients’ confidence in their ability to perform self-care tasks was found to be significantly reduced from baseline to follow up (P = .045).

Conclusions

An Internet-based system to aid the management of diabetes appears feasible and well accepted by patients. The pilot study did not identify evidence of an impact on improving quality of life or self-efficacy in patients who used insulin pump therapy.

Brave new worlds: how virtual environments can augment traditional care in the management of diabetes

New technologies, such as online networking tools, offer innovative ways to engage patients in their diabetes care. Second Life (SL) is one such virtual world that allows patients to interact in a 3D environment with peers and healthcare providers. This article presents a framework that demonstrates how applications within SL can be constructed to meet the needs of patients with diabetes, allowing them to attend group visits, learn more about lifestyle changes, and foster a sense of support and emotional well-being. This experiential approach to education may prove more engaging, and therefore successful, than existing strategies. Addressing concerns relating to privacy and liability is a necessary first step to engage providers in this new approach to patient care.

Feasibility of a mobile phone-based data service for functional insulin treatment of type 1 diabetes mellitus patients

Background

Patients with type 1 diabetes mellitus (DM1) have to be active participants in their treatment because they are inevitably responsible for their own day-to-day-care. Availability of mobile Internet access is advancing rapidly and mobile phones are now widely available at low cost. Thus, mobile phones have the potential to assist in daily diabetes management and to enable a telemedical interaction between patients and health care professionals.

Objective

The aim of the study was to evaluate the feasibility and user acceptance of a mobile phone–based data service to assist DM1 patients on intensive insulin treatment.

Methods

A software application called Diab-Memory (based on Java 2 Mobile Edition) has been developed to support patients when entering diabetes-related data with synchronization to the remote database at the monitoring center. The data were then processed to generate statistics and trends, which were provided for the patient and his/her health care professional via a Web portal. The system has been evaluated in the course of a clinical before-after pilot trial. Outcome measures focused on patients’ adherence to the therapy, availability of the monitoring system, and the effects on metabolic status. General user acceptance of the system was evaluated using a questionnaire.

Results

Ten patients (four female) with DM1 participated in the trial. Mean age was 36.6 years (± 11.0 years) and prestudy glycated hemoglobin (HbA_1c) was 7.9% (± 1.1%). A total of 3850 log-ins were registered during the 3 months of the study. The total number of received datasets was 13003, which equates to an average of 14 transmitted parameters per patient per day. The service was well accepted by the patients (no dropouts), and data transmission via mobile phone was successful on the first attempt in 96.5% of cases. Upon completion of the study, a statistically significant improvement in metabolic control was observed (HbA_1c: prestudy 7.9% ± 1.1% versus poststudy 7.5% ± 0.9%;P= .02). While there was a slight decrease in average blood glucose level (prestudy 141.8 mg/dL ± 22.5 mg/dL vs poststudy 141.2 mg/dL ± 23.1 mg/dL;P= .69), the difference was not statistically significant.

Conclusion

The results of the clinical pilot trial indicate that this proposed diabetes management system was well accepted by the patients and practical for daily usage. Thus, using the mobile phone as patient terminal seems to provide a ubiquitous, easy-to-use, and cost efficient solution for patient-centered data acquisition in the management of DM1. To confirm the promising results of the pilot trial further research has to be done to study long-term effects on glycemic control and cost-effectiveness.

The contribution of teleconsultation and videoconferencing to diabetes care: a systematic literature review

Background

A systematic literature review was carried out to study the benefits of teleconsultation and videoconferencing on the multifaceted process of diabetes care. Previous reviews focused primarily on usability of technology and considered mainly one-sided interventions.

Objective

The objective was to determine the benefits and deficiencies of teleconsultation and videoconferencing regarding clinical, behavioral, and care coordination outcomes of diabetes care.

Methods

Electronic databases (Medline, PiCarta, PsycINFO, ScienceDirect, Telemedicine Information Exchange, ISI Web of Science, Google Scholar) were searched for relevant publications. The contribution to diabetes care was examined for clinical outcomes (eg, HbA_1c, blood pressure, quality of life), behavioral outcomes (patient-caregiver interaction, self-care), and care coordination outcomes (usability of technology, cost-effectiveness, transparency of guidelines, equity of care access). Randomized controlled trials (RCTs) with HbA_1c as an outcome were pooled using standard meta-analytical methods.

Results

Of 852 publications identified, 39 met the inclusion criteria for electronic communication between (groups of) caregivers and patients with type 1, type 2, or gestational diabetes. Studies that evaluated teleconsultation or videoconferencing not particularly aimed at diabetes were excluded, as were those that described interventions aimed solely at clinical improvements (eg, HbA_1c). There were 22 interventions related to teleconsultation, 13 to videoconferencing, and 4 to combined teleconsultation and videoconferencing. The heterogeneous nature of the identified videoconferencing studies did not permit a formal meta-analysis. Pooled results from the six RCTs of the identified teleconsultation studies did not show a significant reduction in HbA_1c (0.03%, 95% CI = - 0.31% to 0.24%) compared to usual care. There was no significant statistical heterogeneity among the pooled RCTs (χ²₇= 7.99, P = .33). It can be concluded that in the period under review (1994-2006) 39 studies had a scope broader than clinical outcomes and involved interventions allowing patient-caregiver interaction. Most of the reported improvements concerned satisfaction with technology (26/39 studies), improved metabolic control (21/39), and cost reductions (16/39). Improvements in quality of life (6/39 studies), transparency (5/39), and better access to care (4/39) were hardly observed. Teleconsultation programs involving daily monitoring of clinical data, education, and personal feedback proved to be most successful in realizing behavioral change and reducing costs. The benefits of videoconferencing were mainly related to its effects on socioeconomic factors such as education and cost reduction, but also on monitoring disease. Additionally, videoconferencing seemed to maintain quality of care while producing cost savings.

Conclusions

The selected studies suggest that both teleconsultation and videoconferencing are practical, cost-effective, and reliable ways of delivering a worthwhile health care service to diabetics. However, the diversity in study design and reported findings makes a strong conclusion premature. To further the contribution of technology to diabetes care, interactive systems should be developed that integrate monitoring and personalized feedback functions.

A review of web-assisted interventions for diabetes management: maximizing the potential for improving health outcomes

Current endeavors in diabetes care focus on helping patients and providers deal successfully with the complexities of the disease by improving the system of care, expanding the reach of interventions, and empowering patients to engage in self-care behaviors. Internet technologies that combine the broad reach of mass media with the interactive capabilities of interpersonal media provide a wide range of advantages over standard modes of delivery. The technical affordances of Web delivery enable individualization or tailoring, appropriately timed reinforcement of educational messages, social support, improved feedback, and increased engagement. In turn, these have been significantly correlated with improved health outcomes.This article is a narrative review of Web-based interventions for managing type 2 diabetes published from 2000 to 2007 that utilize Web sites, Web portals, electronic medical records, videoconference, interactive voice response, and short messaging systems. The most effective systems link medical management and self-management. Patient satisfaction is highest when the Web-based system gives them the ability to track blood glucose, receive electronic reminders, schedule physician visits, email their health care team, and interact with other diabetic patients. However, comprehensive medical and self-management programs have not been implemented widely outside of systems funded by government agencies. The cost of developing and maintaining comprehensive systems continues to be a challenge and is seldom measured in efficacy studies. Lack of reimbursement for Web-based treatments is also a major barrier to implementation. These barriers must be overcome for widespread adoption and realization of subsequent cost savings.

Stakeholder perspectives on the development of a virtual clinic for diabetes care: qualitative study

Background

The development of the Internet has created new opportunities for health care provision, including its use as a tool to aid the self-management of chronic conditions. We studied stakeholder reactions to an Internet-based “virtual clinic,” which would allow people with diabetes to communicate with their health care providers, find information about their condition, and share information and support with other users.

Objective

The aim of the study was to present the results of a detailed consultation with a variety of stakeholder groups in order to identify what they regard as the desirable, important, and feasible characteristics of an Internet-based intervention to aid diabetes self-management.

Methods

Three focus groups were conducted with 12 people with type 1 diabetes who used insulin pumps. Participants were recruited through a local diabetes clinic. One-on-one interviews were conducted with 5 health care professionals from the same clinic (2 doctors, 2 nurses, 1 dietitian) and with 1 representative of an insulin pump company. We gathered patient consensus via email on the important and useful features of Internet-based systems used for other chronic conditions (asthma, epilepsy, myalgic encephalopathy, mental health problems). A workshop to gather expert consensus on the use of information technology to improve the care of young people with diabetes was organized.

Results

Stakeholder groups identified the following important characteristics of an Internet-based virtual clinic: being grounded on personal needs rather than only providing general information; having the facility to communicate with, and learn from, peers; providing information on the latest developments and news in diabetes; being quick and easy to use. This paper discusses these characteristics in light of a review of the relevant literature. The development of a virtual clinic for diabetes that embodies these principles, and that is based on self-efficacy theory, is described.

Conclusions

Involvement of stakeholders is vital early in the development of a complex intervention. Stakeholders have clear and relevant views on what a virtual clinic system should provide, and these views can be captured and synthesized with relative ease. This work has led to the design of a system that is able to meet user needs and is currently being evaluated in a pilot study.

Pilot study of an Internet patient-physician communication tool for heart failure disease management

BACKGROUND

Internet disease management has the promise of improving care in patients with heart failure but evidence supporting its use is limited. We have designed a Heart Failure Internet Communication Tool (HFICT), allowing patients to enter messages for clinicians, as well as their daily symptoms, weight, blood pressure and heart rate. Clinicians review the information on the same day and provide feedback.

OBJECTIVE

This pilot study evaluated the feasibility and patients' acceptability of using the Internet to communicate with patients with symptomatic heart failure.

METHODS

Patients with symptomatic heart failure were instructed how to use the Internet communication tool. The primary outcome measure was the proportion of patients who used the system regularly by entering information on average at least once per week for at least 3 months. Secondary outcomes measures included safety and maintainability of the tool. We also conducted a content analysis of a subset of the patient and clinician messages entered into the comments field.

RESULTS

Between May 3, 1999 and November 1, 2002, 62 patients (mean age 48.7 years) were enrolled.. At 3 months 58 patients were alive and without a heart transplant. Of those, 26 patients (45%; 95% Confidence Interval, 0.33-0.58) continued using the system at 3 months. In 97% of all entries by participants weight was included; 68% of entries included blood pressure; and 71% of entries included heart rate. In 3386 entries out of all 5098 patient entries (66%), comments were entered. Functions that were not used included the tracking of diuretics, medications and treatment goals. The tool appeared to be safe and maintainable. Workload estimates for clinicians for entering a response to each patient's entry ranged from less than a minute to 5 minutes or longer for a detailed response. Patients sent 3386 comments to the Heart Function Clinic. Based on the content analysis of 100 patient entries, the following major categories of communication were identified: patient information; patient symptoms; patient questions regarding their condition; patient coordinating own care; social responses. The number of comments decreased over time for both patients and clinicians.

CONCLUSION

While the majority of patients discontinued use, 45% of the patients used the system and continued to use it on average for 1.5 years. An Internet tool is a feasible method of communication in a substantial proportion of patients with heart failure. Further study is required to determine whether clinical outcomes, such as quality of life or frequency of hospitalization, are improved.

Patient-perceived usefulness of online electronic medical records: employing grounded theory in the development of information and communication technologies for use by patients living with chronic illness

OBJECTIVE

Patient use of online electronic medical records (EMR) holds the potential to improve health outcomes. The purpose of this study is to discover how patients living with chronic inflammatory bowel disease (IBD) value Internet-based patient access to electronic patient records.

DESIGN

This was a qualitative, exploratory, descriptive study using in-depth interviews and focus groups of a total of 12 patients with IBD of at least one-year duration at University Health Network, a tertiary care center in Toronto, Ontario.

RESULTS

Four themes have been elucidated that comprise a theoretical framework of patient-perceived information and communication technology usefulness: promotion of a sense of illness ownership, of patient-driven communication, of personalized support, and of mutual trust.

CONCLUSIONS

For patients with chronic IBD, simply providing access to electronic medical records has little usefulness on its own. Useful technology for patients with IBD is multifaceted, self-care promoting, and integrated into the patient's already existing health and psychosocial support infrastructure. The four identified themes can serve as focal points for the evaluation of information technology designed for patient use, thus providing a patient-centered framework for developers seeking to adapt existing EMR systems to patient access and use for the purposes of improving health care quality and health outcomes. Further studies in other populations are needed to enhance generalizability of the emergent theory.

HealthCyberMap: a semantic visual browser of medical Internet resources based on clinical codes and the human body metaphor

OBJECTIVES

HealthCyberMap (HCM-http://healthcybermap.semanticweb.org) is a web-based service for healthcare professionals and librarians, patients and the public in general that aims at mapping parts of the health information resources in cyberspace in novel ways to improve their retrieval and navigation.

METHODS AND SERVICE DESCRIPTION

HCM adopts a clinical metadata framework built upon a clinical coding ontology for the semantic indexing, classification and browsing of Internet health information resources. A resource metadata base holds information about selected resources. HCM then uses GIS (Geographic Information Systems) spatialization methods to generate interactive navigational cybermaps from the metadata base. These visual cybermaps are based on familiar medical metaphors.

CONCLUSIONS

HCM cybermaps can be considered as semantically spatialized, ontology-based browsing views of the underlying resource metadata base. Using a clinical coding scheme as a metric for spatialization ('semantic distance') is unique to HCM and is very much suited for the semantic categorization and navigation of Internet health information resources. Clinical codes ensure reliable and unambiguous topical indexing of these resources. HCM also introduces a useful form of cyberspatial analysis for the detection of topical coverage gaps in the resource metadata base using choropleth (shaded) maps of human body systems.