Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet

IN BRIEF Chronic conditions such as diabetes are largely managed by primary care providers (PCPs), with significant patient self-management. This article describes the development, pilot testing, and fine-tuning of a Web-based digital health solution to help PCPs manage patients with cardiometabolic diseases during routine office encounters. It shows that such products can be successfully integrated into primary care settings when they address important unmet needs and are developed with input from end-users.

Background: The Floodlight Open app is a digital health technology tool (DHTT) that comprises remote, smartphone sensor–based tests (daily activities) for assessing symptoms of multiple sclerosis (MS). User acquisition, engagement, and retention remain a barrier to successfully deploying such tools. Objective: This study aims to quantitatively and qualitatively investigate key user experience (UX) factors associated with the Floodlight Open app. Methods: Floodlight Open is a global, open-access, digital-only study designed to understand the drivers and barriers in deploying a DHTT in a naturalistic setting without supervision and onboarding by a clinician. Daily activities included tests assessing cognition (Information Processing Speed and Information Processing Speed Digit–Digit), hand-motor function (Pinching Test and Draw a Shape Test), and postural stability and gait (Static Balance Test, U-Turn Test, and Two-Minute Walk Test [2MWT]). All daily activities except the 2MWT were taken in a fixed sequence. Qualitative UX was studied through semistructured interviews in a substudy of US participants with MS. The quantitative UX analysis investigated the impact of new UX design features on user engagement and retention in US participants for 3 separate test series: all daily activities included in the fixed sequence (DA), all daily activities included in the fixed sequence except the Static Balance Test and U-Turn Test (DAx), and the 2MWT. Results: The qualitative UX substudy (N=22) revealed the need for 2 new UX design features: a more seamless user journey during the activation process that eliminates the requirement of switching back and forth between the app and the email that the participants received upon registration, and configurable reminders and push notifications to help plan and remind the participants to complete their daily activities. Both UX design features were assessed in the quantitative UX analysis. Introducing the more seamless user journey (original user journey: n=608; more seamless user journey: n=481) improved the conversion rate of participants who enrolled in the study and proceeded to successfully activate the app from 53.9% (328/608) to 74.6% (359/481). Introducing reminders and push notifications (with reminders and notifications: n=350; without reminders and notifications: n=172) improved continuous usage time (proportion of participants with ≥3 consecutive days of usage: DA and DAx: ~30% vs ~12%; 2MWT: ~30% vs ~20%); test completion rates (maximum number of test series completed: DA: 279 vs 64; DAx: 283 vs 126; 2MWT: 302 vs 76); and user retention rates (at day 30: DA: 53/172, 30.8% vs 34/350, 9.7%; DAx: 53/172, 30.8% vs 60/350, 17.1%; 2MWT: 39/172, 22.6% vs 22/350, 6.2%). Inactivity times remained comparable. Conclusions: The remote assessment of MS with DHTTs is a relatively nascent but growing field of research. The continued assessment and improvement of UX design features can play a crucial role in the successful long-term adoption of new DHTTs.

The objective of this study was to determine the strengths and limitations of using structured electronic health records (EHR) to identify and manage cardiometabolic (CM) health gaps. We used medication adherence measures derived from dispense data to attribute related therapeutic care gaps (i.e., no action to close health gaps) to patient- (i.e., failure to retrieve medication or low adherence) or clinician-related (i.e., failure to initiate/titrate medication) behavior. We illustrated how such data can be used to manage health and care gaps for blood pressure (BP), low-density lipoprotein cholesterol (LDL-C), and HbA1c for 240,582 Sutter Health primary care patients. Prevalence of health gaps was 44% for patients with hypertension, 33% with hyperlipidemia, and 57% with diabetes. Failure to retrieve medication was common; this patient-related care gap was highly associated with health gaps (odds ratios (OR): 1.23–1.76). Clinician-related therapeutic care gaps were common (16% for hypertension, and 40% and 27% for hyperlipidemia and diabetes, respectively), and strongly related to health gaps for hyperlipidemia (OR = 5.8; 95% CI: 5.6–6.0) and diabetes (OR = 5.7; 95% CI: 5.4–6.0). Additionally, a substantial minority of care gaps (9% to 21%) were uncertain, meaning we lacked evidence to attribute the gap to either patients or clinicians, hindering efforts to close the gaps.

Background: Electronic health record (EHR) systems are becoming increasingly complicated, leading to concerns about rising physician burnout, particularly for primary care physicians (PCPs). Managing the most common cardiometabolic chronic conditions by PCPs during a limited clinical time with a patient is challenging. Objective: This study aimed to evaluate a Cardiometabolic Sutter Health Advanced Reengineered Encounter (CM-SHARE), a web-based application to visualize key EHR data, on the EHR use efficiency. Methods: We developed algorithms to identify key clinic workflow measures (eg, total encounter time, total physician time in the examination room, and physician EHR time in the examination room) using audit data, and we validated and calibrated the measures with time-motion data. We used a pre-post parallel design to identify propensity score-matched CM-SHARE users (cases), nonusers (controls), and nested-matched patients. Cardiometabolic encounters from matched case and control patients were used for the workflow evaluation. Outcome measures were compared between the cases and controls. We applied this approach separately to both the CM-SHARE pilot and spread phases. Results: Time-motion observation was conducted on 101 primary care encounters for 9 PCPs in 3 clinics. There was little difference (<0.8 minutes) between the audit data-derived workflow measures and the time-motion observation. Two key unobservable times from audit data, physician entry into and exiting the examination room, were imputed based on time-motion studies. CM-SHARE was launched with 6 pilot PCPs in April 2016. During the prestudy period (April 1, 2015, to April 1, 2016), 870 control patients with 2845 encounters were matched with 870 case patients and encounters, and 727 case patients with 852 encounters were matched with 727 control patients and 3754 encounters in the poststudy period (June 1, 2016, to June 30, 2017). Total encounter time was slightly shorter (mean -2.7, SD 1.4 minutes, 95% CI -4.7 to -0.9; mean -1.6, SD 1.1 minutes, 95% CI -3.2 to -0.1) for cases than controls for both periods. CM-SHARE saves physicians approximately 2 minutes EHR time in the examination room (mean -2.0, SD 1.3, 95% CI -3.4 to -0.9) compared with prestudy period and poststudy period controls (mean -1.9, SD 0.9, 95% CI -3.8 to -0.5). In the spread phase, 48 CM-SHARE spread PCPs were matched with 84 control PCPs and 1272 cases with 3412 control patients, having 1119 and 4240 encounters, respectively. A significant reduction in total encounter time for the CM-SHARE group was observed for short appointments (<= 20 minutes; 5.3-minute reduction on average) only. Total physician EHR time was significantly reduced for both longer and shorter appointments (17%-33% reductions). Conclusions: Combining EHR audit log files and clinical information, our approach offers an innovative and scalable method and new measures that can be used to evaluate clinical EHR efficiency of digital tools used in clinical settings.

BACKGROUND The Floodlight Open app is a digital health technology tool (DHTT) that comprises remote, smartphone sensor–based tests (daily activities) for assessing symptoms of multiple sclerosis (MS). User acquisition, engagement, and retention remain a barrier to successfully deploying such tools. OBJECTIVE This study aims to quantitatively and qualitatively investigate key user experience (UX) factors associated with the Floodlight Open app. METHODS Floodlight Open is a global, open-access, digital-only study designed to understand the drivers and barriers in deploying a DHTT in a naturalistic setting without supervision and onboarding by a clinician. Daily activities included tests assessing cognition (Information Processing Speed and Information Processing Speed Digit–Digit), hand-motor function (Pinching Test and Draw a Shape Test), and postural stability and gait (Static Balance Test, U-Turn Test, and Two-Minute Walk Test [2MWT]). All daily activities except the 2MWT were taken in a fixed sequence. Qualitative UX was studied through semistructured interviews in a substudy of US participants with MS. The quantitative UX analysis investigated the impact of new UX design features on user engagement and retention in US participants for 3 separate test series: all daily activities included in the fixed sequence (DA), all daily activities included in the fixed sequence except the Static Balance Test and U-Turn Test (DAx), and the 2MWT. RESULTS The qualitative UX substudy (N=22) revealed the need for 2 new UX design features: a more seamless user journey during the activation process that eliminates the requirement of switching back and forth between the app and the email that the participants received upon registration, and configurable reminders and push notifications to help plan and remind the participants to complete their daily activities. Both UX design features were assessed in the quantitative UX analysis. Introducing the more seamless user journey (original user journey: n=608; more seamless user journey: n=481) improved the conversion rate of participants who enrolled in the study and proceeded to successfully activate the app from 53.9% (328/608) to 74.6% (359/481). Introducing reminders and push notifications (with reminders and notifications: n=350; without reminders and notifications: n=172) improved continuous usage time (proportion of participants with ≥3 consecutive days of usage: DA and DAx: ~30% vs ~12%; 2MWT: ~30% vs ~20%); test completion rates (maximum number of test series completed: DA: 279 vs 64; DAx: 283 vs 126; 2MWT: 302 vs 76); and user retention rates (at day 30: DA: 53/172, 30.8% vs 34/350, 9.7%; DAx: 53/172, 30.8% vs 60/350, 17.1%; 2MWT: 39/172, 22.6% vs 22/350, 6.2%). Inactivity times remained comparable. CONCLUSIONS The remote assessment of MS with DHTTs is a relatively nascent but growing field of research. The continued assessment and improvement of UX design features can play a crucial role in the successful long-term adoption of new DHTTs.