Terence Tang

BACKGROUND Transition from hospital to home is a vulnerable time for patients with multimorbidity (i.e., the occurrence of 2+ chronic conditions) due to the complexity of care and risk of complications. One way to improve care transitions is through technologies that enable effective communication between hospital/primary care providers and with patients. OBJECTIVE This study aims to evaluate the usability of the Digital Bridge tool, a communication tool to enable transitions from hospital to home, to guide the design and development process. METHODS The study follows a multi-method approach involving both a quantitative survey and a qualitative approach (i.e., think-aloud exercise and cognitive walkthrough). Data were collected via think-aloud, cognitive walkthrough, and Post-Study System Usability Questionnaire (PSSUQ) and analyzed through rapid qualitative analysis and descriptive statistics. RESULTS Users reported positive usability experiences with the technology. 19 participants completed the PSSUQ (mean score: 2.97) with the benchmark mean at 2.82 (99% CI 2.62–3.02). Given that the observed overall PSSUQ score falls within the confidence interval of the benchmark, this indicates a positive usability experience across participants. Insights from the qualitative data indicated that although both providers and patients have similar communication needs around care transitions, such as access to up-to-date discharge information to facilitate smooth transitions for patients, their priorities differed. For instance, providers indicated their need for technology that integrates into clinical workflows, while patients require technology that easily helps them manage their care. CONCLUSIONS The differing priorities from both user groups pose an interesting implementation challenge, emphasizing the need for iterative design and continuous usability testing. This ensures that the technology is tailored to meet the unique needs of both user groups. CLINICALTRIAL The broader Digital Bridge study is registered with ClinicalTrials.gov (NCT04287192; https://clinicaltrials.gov/ct2/show/NCT04287192). The present manuscript reports findings from a usability sub-study conducted within the broader registered research program.

BACKGROUND Developing digital health solutions for complex health service environments poses a unique design challenge. Service models, like transitions from hospital-to-home for older adults with complex care needs, represent dynamic contexts in which multiple user types are working across diverse settings and workflows. Designing digital health solutions for these types of environments requires advancing traditional methods intended to design for the needs of single user groups working in more bounded settings. OBJECTIVE This study addresses this design challenge by combing Design Thinking and co-design methods to develop a digitally enabled hospital-to-home communication platform to meet the needs of older adult patients with complex care needs, their caregivers and hospital and primary care clinicians who are involved in the transition process. To co-design the Digital Bridge tool, the study was guided by two questions addressed in this paper: 1) How can we translate diverse user groups’ needs into technology features? And 2) Can incorporating a Design Thinking-driven process as part of user-centred co-design help to manage tensions with diverse user groups perspectives? METHODS The Institute of Design at Stanford’s Design Thinking approach (empathize, define, ideate, prototype and test) was applied to guide co-design of the tool; leveraging multiple virtual platforms (e.g. Zoom, Jamboards, journey maps), research methods (e.g. interviews, working groups, asynchronous feedback, surveys), and informatics tools (e.g. information flow and business process maps). Working groups consisting of patients and caregivers, hospital and primary care clinicians, and the project’s Citizen Advisory Committee. Working groups engaged in multiple-iterative design phases with the research and design team to adapt two existing technologies into the new Digital Bridge platform. RESULTS Pre-design work involving interviews with patients and caregivers identified nine challenges in the hospital-to-home transition process, including communication barriers, feeling rushed and invisible, and not knowing where to go when help was needed. Challenges acted as design anchors, guiding a series of five working group sessions with patients and caregivers (n=9), five working group sessions with hospital (acute and rehab sites) and primary care clinicians (n=28) and a round of surveys. Needs were mapped onto six tangible design functions and integrated in two separate technology platforms to align to the local digital ecosystems and workflows at two hospitals networks in Canada. Working across user groups, tensions around language and workflow surfaced and were addressed by prioritizing the patient- and caregiver-identified challenges, while maintaining a person-centred lens. CONCLUSIONS The Design Thinking approach was useful in guiding the co-design process, however, effective collaboration across diverse user groups required iterative rather than linear movement between stages of the Design Thinking approach. Future co-design projects working across diverse groups should consider embedding shared-empathy activities to manage tensions and develop true person-centred solutions. CLINICALTRIAL ClinicalTrials.gov NCT04287192; https://clinicaltrials.gov/ct2/show/NCT04287192 INTERNATIONAL REGISTERED REPORT RR2-10.2196/20220

Participant feedback can help researchers identify aspects to consider and improve in the design of future studies. In this study, we explored the experiences and perceptions of participants who participated in a photovoice study, and their thoughts on how the study could be improved to enhance participant experiences, accessibility and inclusivity. Fourteen racialized individuals impacted by stroke, including individuals who have experienced a stroke ( n = 11) and stroke caregivers ( n = 3), participated in this qualitative interpretive descriptive study via one post-photovoice interview to share their experiences and perspectives in the photovoice study. Three themes were generated following Thorne’s interpretive description analysis approach. Theme 1 ‘motivators, enablers, barriers and opportunities to enhance participation in a photovoice study’ highlighted participants’ motivations to participate in the photovoice study and potential barriers that could limit participation by some in the study. Theme 2 ‘meeting diverse participant needs and preferences in the photovoice study’ highlighted participants’ thoughts on how researchers could enhance participant experiences, accessibility and inclusivity in a photovoice study within the study’s structure and logistics, photo-taking, individual interviews and focus groups. Theme 3 highlighted participants’ thoughts on the benefits of study participation, including the direct and indirect benefits (or lack thereof) and their opinions about the honorarium. While these findings only reflect the experiences of 14 participants in a single photovoice study, they may offer valuable insights for researchers looking to critically assess and refine their own methods. In particular, they highlight the importance of designing approaches that are inclusive, accessible and responsive to the diverse needs of participants.

Racialized individuals are underrepresented in stroke research despite reporting unmet recovery needs. Understanding self-management experiences can inform service delivery improvements. In this study, we aimed to explore experiences of stroke self-management and recovery. Racialized adults (residing in Canada, self-identifying as non-White or Indigenous) living with stroke and caregivers participated. Photovoice methods involved: 1) initial interview; 2) participants' photographs illustrating important, joyful, and challenging aspects after stroke, strategies for overcoming challenges, and hopes/goals for recovery; 3) individual interview; and 4) focus group. Data were analyzed using thematic analysis. Fourteen individuals living with stroke and five caregivers participated. Themes highlighted the joy in daily life from cherished relationships and food, mealtimes, and preparing meals. Participants navigated personal and cultural factors in stroke self-management and recovery, and their recovery hopes and goals included maximizing independence and resuming valued activities. These findings capture the experiences of racialized participants and reinforce the need for individualized and culturally appropriate stroke services to address ongoing challenges. Our findings highlight the importance of understanding what is meaningful after a stroke and how to support engagement in activities and roles that are most important to each person at that particular recovery stage.

Digital health interventions are complex, involving the interactions of organizations, people, workflows, and technology. Adaptability is needed in both implementation and evaluation strategies to meet the needs of organizations, clinicians, patients, and researchers. The Digital Bridge project aims to co-design, implement, and evaluate a digitally enabled care transition intervention for older adults with complex needs. We encountered varying ability of partners to engage at different times, alongside changes in technology infrastructure, vendor, and healthcare services offered including unanticipated emergence of other care transition interventions. Through collaboration with health system partners, implementation and evaluation strategies were adapted. In evaluating digital health interventions, adaptability and flexibility in implementation strategies and evaluation methods are needed to meet the real-world need of delivering digital health interventions at scale. The Learning Health System Action Framework may offer insights as to how to address these tensions.

Objective This study explored experiences with implementing and using the Epic electronic health record (EHR) across different clinical programmes within a single Canadian hospital system and specifically examined how local configuration decisions and implementation of its features and functionalities integrated well or introduced friction within workflows. Design Qualitative description methodology involving semistructured interviews analysed using thematic analysis. Setting A large community hospital in Canada. Participants Healthcare providers, administrative staff and clinical leaders from seven clinical programmes. Results 66 individuals participated in interviews. Participants described that Epic’s implementation impacted communication and teamwork, workflow and efficiency, and patient care, with these impacts varying across different programme settings. Participants reported that Epic improved inpatient care and safety, communication and teamwork, workflow and efficiency. However, several programmes also experienced challenges, including information overload and increased clerical tasks, impacting workflow efficiency. In programmes with an outpatient component, such as surgery and oncology, there were additional difficulties, such as connecting with external partners, user interface complexities that hindered task completion and concerns about potential compromises in patient care quality. Conclusion Health systems must consider the diverse needs of various clinical programmes when implementing an EHR. Customising the system interface and iteratively codesigning how health system staff incorporate the technology into their workflows are crucial to ensure an EHR seamlessly integrates across different settings, fosters high-quality care delivery and minimises user friction.

Objective This study aimed to describe how healthcare providers perceived the impacts of implementing and using an electronic health record (EHR) on quality, safety and person-centredness of care. Design A qualitative descriptive design using semistructured interviews. Setting In October 2020, a large Canadian community hospital implemented a new EHR system (Epic) across three sites, transitioning from a previously fragmented (combination of paper-based and electronic) system. Participants Sixty-two healthcare providers and clinical leaders. Results Participants shared their experiences regarding the impact of EHR implementation on quality of care, which were analysed into common themes including task efficiency, information management, patient interactions and patient safety. While the system significantly altered their routines and introduced new responsibilities like additional documentation requirements, it also facilitated adherence to clinical guidelines, improved information visibility and enhanced documentation, benefiting overall quality of care and patient safety. Participants reported that EHR implementation led to increased efficiency, freeing up time for patient care and improving communication with patients and other providers. Conclusion EHRs have the potential to improve quality of care and patient safety, but this depends on their perceived value and how well healthcare providers can integrate their various features into clinical routines.

Background: Health systems are increasingly offering patient portals as tools for patients to access their health information with the goal of improving engagement in care. However, understanding health care providers’ perspectives on patient portal implementation is crucial. Objective: This study aimed to understand health care providers’ experiences of implementing the MyChart patient portal, perspectives about its impact on patient care, clinical practice, and workload, and opportunities for improvement. Methods: Using an explanatory sequential mixed methods approach, we conducted a web-based questionnaire and semistructured individual interviews with health care providers at a large Canadian community hospital, 6 months after MyChart was first offered to patients. We explored perspectives about the impact of MyChart on clinical practice, workload, and patient care. Data were analyzed using descriptive statistics and thematic analysis. Results: In total, 261 health care providers completed the web-based questionnaire, and 15 also participated in interviews. Participants agreed that patients should have access to their health information through MyChart and identified its benefits such as patients gaining a greater understanding of their own health, which could improve patient safety (160/255, 62%). While many health care providers agreed that MyChart supported better patient care (108/258, 42%), there was limited understanding of features available to patients and expectations for integrating MyChart into clinical routines. Concerns were raised about the potential negative impacts of MyChart on patient-provider relationships because sensitive notes or results could be inappropriately interpreted (109/251, 43%), and a potential increase in workload if additional portal features were introduced. Suggested opportunities for improvement included support for both patients and health care providers to learn about MyChart and establishing guidelines for health care providers on how to communicate information available in MyChart to patients. Conclusions: While health care providers acknowledged that MyChart improved patients’ access to health information, its implementation introduced some friction and concerns. To reduce the risk of these challenges, health systems can benefit from engaging health care providers early to identify effective patient portal implementation strategies.