Jennifer Knopf Munafo

Usability Testing Finds Problems for Novice Users of Pediatric Portals

OBJECTIVE Patient portals may improve pediatric chronic disease outcomes, but few have been rigorously evaluated for usability by parents. Using scenario-based testing with think-aloud protocols, we evaluated the usability of portals for parents of children with cystic fibrosis, diabetes or arthritis. DESIGN Sixteen parents used a prototype and test data to complete 14 tasks followed by a validated satisfaction questionnaire. Three iterations of the prototype were used. MEASUREMENTS During the usability testing, we measured the time it took participants to complete or give up on each task. Sessions were videotaped and content-analyzed for common themes. Following testing, participants completed the Computer Usability Satisfaction Questionnaire which measured their opinions on the efficiency of the system, its ease of use, and the likeability of the system interface. A 7-point Likert scale was used, with seven indicating the highest possible satisfaction. RESULTS Mean task completion times ranged from 73 (+/- 61) seconds to locate a document to 431 (+/- 286) seconds to graph laboratory results. Tasks such as graphing, location of data, requesting access, and data interpretation were challenging. Satisfaction was greatest for interface pleasantness (5.9 +/- 0.7) and likeability (5.8 +/- 0.6) and lowest for error messages (2.3 +/- 1.2) and clarity of information (4.2 +/- 1.4). Overall mean satisfaction scores improved between iteration one and three. CONCLUSIONS Despite parental involvement and prior heuristic testing, scenario-based testing demonstrated difficulties in navigation, medical language complexity, error recovery, and provider-based organizational schema. While such usability testing can be expensive, the current study demonstrates that it can assist in making healthcare system interfaces for laypersons more user-friendly and potentially more functional for patients and their families.

The In Vivo Adherence Intervention For at Risk Adolescents With Asthma: Report of a Randomized Pilot Trial

OBJECTIVE Low-income and minority adolescents are at high risk for poor asthma outcomes, due in part to adherence. We tested acceptability, feasibility, and effect sizes of an adherence intervention for low socioeconomic status (SES) minority youth with moderate- and severe-persistent asthma. Design and Methods Single-site randomized pilot trial: intervention (n = 12; asthma education, motivational interviewing, problem-solving skills training, 1 month cell-phone with tailored text messaging) versus control (n = 14; asthma education; cell-phone without tailored messaging). Calculated effect-sizes of relative change from baseline (1 and 3 months). RESULTS Intervention was judged acceptable and feasible by participants. Participants (12-18 years, mean = 15.1, SD = 1.67) were 76.9% African-American, 80.7% public/no insurance. At 1 and 3 months, asthma symptoms (Cohens ds = 0.40, 0.96) and HRQOL (PedsQL™; Cohens ds = 0.23, 1.25) had clinically meaningful medium to large effect sizes. CONCLUSIONS This intervention appears promising for at-risk youth with moderate- and severe-persistent asthma.

Pilot and Feasibility Test of Adolescent-Controlled Text Messaging Reminders

Purpose. This pilot study assessed the feasibility, acceptability, and utility of a text messaging system that allowed teenagers with asthma to generate and control medical reminders sent to their mobile phones. Methods. The 12 teens in the study group were able to create their own reminder text messages, add or change reminders, and determine when and how often the messages were sent to their cell phone. Results. In total, 18 of the 21 unique messages created were reminders to take medication. No teen made changes to their original text messages or delivery schedule on their own. They gave high ratings on the usefulness, acceptability, and ease of use of the text messaging system. Self-reported asthma control at baseline was similar for both the study and comparison groups and did not change significantly. Conclusions. Allowing teens to control the timing and content of reminder text messages may support self-management of chronic disease.

Variation in Use of Internet-Based Patient Portals by Parents of Children With Chronic Disease

OBJECTIVES To assess the use of Internet-based portals among families of children with chronic diseases and to describe characteristics of portal registrants and users. DESIGN Retrospective observational study. SETTING Cincinnati Childrens Hospital Medical Center, Cincinnati, Ohio, using data from September 1, 2003, through February 29, 2008. Patients/ PARTICIPANTS Parents of children with diabetes mellitus, juvenile idiopathic arthritis, or cystic fibrosis. INTERVENTIONS Parents of children with a chronic disease were given the opportunity to access health-related information for their children via an Internet-based portal. OUTCOME MEASURES Percentage of families who obtained a portal account (registered), used the portal for the first time within 3 months and again 3 to 6 months after registration, number of times logged in, and session length. RESULTS Of 1900 families, 27.9% obtained a portal account. Of those, 47.8% used the portal within 3 months of registration and 15.9% continued to use the portal 3 to 6 months after registration. Families of African American patients and of patients insured by Medicaid were less likely to obtain a portal account. More outpatient visits and having private health insurance coverage were associated with increased portal registration and use. CONCLUSIONS Understanding the feasibility of portal use by parents is an important first step to using portals for improving self-management, patient-provider interactions, and outcomes for children with chronic diseases. Subsequent studies should address parent perceptions of the value portals add to the management of the chronic disease of their child and ways to increase that value. Barriers to using portals among racial minorities and publicly insured families should also be studied to address disparities.

Family perceptions of the usability and value of chronic disease web-based patient portals

The objective of this study was to understand perceptions of the usability and value of web-based patient portals among parents of children with a chronic condition (diabetes, juvenile idiopathic arthritis, and cystic fibrosis). The design was a cross-sectional telephone survey with semistructured interviews and was conducted at a tertiary children’s hospital. Parent ratings of their experiences with and the value of a web-based portal and reasons for not using the portal were ascertained. Most parents agreed that the portal information was accurate, timely, and useful. Confidentiality and seeing worrisome health-related information about their child was not a major concern, and parents felt that the portal helped to improve their understanding of and ability to manage their child’s condition. In conclusion, the results of this study support the notion that web-based patient portals have the potential to be a useful tool for parents of children with a chronic disease.

Improving Outcomes for Underserved Adolescents With Asthma

BACKGROUND AND OBJECTIVE: Asthma is the most common chronic disease of childhood. Treatment adherence by adolescents is often poor, and their outcomes are worse than those of younger patients. We conducted a quality improvement initiative to improve asthma control and outcomes for high-risk adolescents treated in a primary care setting. METHODS: Interventions were guided by the Chronic Care Model and focused on standardized and evidence-based care, care coordination and active outreach, self-management support, and community connections. RESULTS: Patients with optimally well-controlled asthma increased from ∼10% to 30%. Patients receiving the evidence-based care bundle (condition/severity characterized in chart and, for patients with persistent asthma, an action plan and controller medications at the most recent visit) increased from 38% to at or near 100%. Patients receiving the required self-management bundle (patient self-assessment, stage-of-readiness tool, and personal action plan) increased from 0% to ∼90%. Patients and parents who were confident in their ability to manage their or their adolescent’s asthma increased from 70% to ∼85%. Patient satisfaction and the mean proportion of patients with asthma-related emergency department visits or hospitalizations remained stable at desirable levels. CONCLUSIONS: Implementing interventions focused on standardized and evidence-based care, self-management support, care coordination and active outreach, linkage to community resources, and enhanced follow-up for patients with chronically not-well-controlled asthma resulted in sustained improvement in asthma control in adolescent patients. Additional interventions are likely needed for patients with chronically poor asthma control.

Improving Notification of Sexually Transmitted Infections: A Quality Improvement Project and Planned Experiment

BACKGROUND AND OBJECTIVE: Inadequate follow-up of positive sexually transmitted infection (STI) test results is a gap in health care quality that contributes to the epidemic of STIs in adolescent women. The goal of this study was to improve our ability to contact adolescent women with positive STI test results after an emergency department visit. METHODS: We conducted an interventional quality improvement project at a pediatric emergency department. Phase 1 included plan-do-study-act cycles to test interventions such as provider education and system changes. Phase 2 was a planned experiment studying 2 interventions (study cell phone and patient activation card), using a 2 × 2 factorial design with 1 background variable and 2 replications. Outcomes were: (1) the proportion of women aged 14 to 21 years with STI testing whose confidential telephone number was documented in the electronic medical record; (2) the proportion of STI positive women successfully contacted within 7 days. RESULTS: Phase 1 interventions increased the proportion of records with a confidential number from 24% to 58% and the proportion contacted from 45% to 65%, and decreased loss to follow-up from 40% to 24%. In phase 2, the proportion contacted decreased after the electronic medical record system changed and recording of the confidential number decreased. Study interventions (patient activation card and study cell phone) had a synergistic effect on successful contact, especially when confidential numbers were less reliably documented. CONCLUSIONS: Feasible and sustainable interventions such as improved documentation of a confidential number worked synergistically to increase our ability to successfully contact adolescent women with their STI test results.

Direct care nurses on the shared governance journey towards positive patient outcomes

AIMS AND OBJECTIVES To describe shared governance in action through the example of one paediatric institutions decision to institute daily chlorhexidine bathing. BACKGROUND Shared governance processes are discussed extensively in the literature; however, implementation of the processes can be challenging. Recently nurses at one paediatric hospital were involved in a hospital-wide practice change where the theoretical approach of shared governance was actualised. Several questions arose from direct care nurses about unwarranted variations in bathing practices across settings and whether bathing standardisation could address the recent increase in central line-associated bloodstream infections. Shared governance council members identified daily chlorhexidine bathing as a potential intervention to standardise bathing across the hospital and to decrease infection rates. At this time, chlorhexidine bathing had been widely adopted in adult hospitals but was less commonly practiced in paediatric institutions. DESIGN This is a position paper describing the use of shared governance to make a house-wide practice decision and positively impact patient outcomes. METHOD Inquiry Council members conducted a systematic evidence search on best practices around chlorhexidine bathing. This evidence was used in Practice Council discussions to standardise house-wide practice. Once consensus was achieved, council members collaborated with Education Council to ensure understanding, competency, and the adoption and sustainment of the practice change. CONCLUSIONS Patients with central lines are at decreased risk for acquiring a central line-associated blood stream infection due, in part, to the change in nursing practice to include daily chlorhexidine bathing. The shared governance structure was the vehicle through which this practice was vetted and instituted. RELEVANCE TO CLINICAL PRACTICE This paper provides a real-life example of leveraging shared governance structures and the direct care nurse leaders within the councils when an organisation faces critical needs in patient care.

Pediatric emergency department provider perceptions of universal sexually transmitted infection screening.

The purpose of this study was to describe the perceptions of pediatric emergency care providers in relation to implementing a universal sexually transmitted infection screening process for adolescent female patients in a pediatric emergency department. A descriptive qualitative design was used with a convenience sample of pediatric emergency physicians and nurses working in a large urban, pediatric teaching hospital. Participants were individually interviewed using a standard interview guide. Verbatim transcripts were analyzed using a modified constant comparative analysis method. Three overriding themes were identified that describe the perceptions of providers in relation to a universal screening process in a pediatric emergency department: Attitudes, Barriers, and Solutions. Universal sexually transmitted infection screening is one strategy that may help with early identification and treatment of adolescent female patients with undiagnosed sexually transmitted infections, and the pediatric emergency department is a potential site for such screening.

The Conference Facilitator Model: Improving the Value of Conference Attendance for Attendees and the Organization.

Healthcare leaders face a multitude of priorities demanding their attention and resources, from patient, employee safety and hospital-acquired conditions to predicting future revenue in the context of healthcare reform. Assessing value requires balancing outcomes and experience with cost. How does allocating funds for professional nursing conferences measure up? What is a valid return on investment when we send staff nurses to professional conferences, specifically the annual Magnet® conference? The following article describes how Cincinnati Children’s Hospital Medical Center answered these questions and redefined the expectations for conference attendees while enhancing the experience and the reportable outcomes for practice and the organization.