Service Desk Calls in a Home-based Clinical Informatics Study: Supporting End Users in the Field

Abstract

Home-based clinical informatics technologies are being developed to facilitate health care provision and management. Given the novelty of these technologies, end users such as patients and their formal and informal caregivers may require support during use. This paper presents a case study within the United States of the service desk calls generated over a 31-month period by patients enrolled in a large randomized field experiment, HeartCare II. This case study provides future deployers of home-based clinical information technologies with an understanding of the types of support that may be required during use. Our analysis reveals that calls to the service desk originated as a result of user problems, hardware problems, software problems, and internal communication problems among individuals involved in the delivery and use of the technology. Implications of these needs for support during use are also discussed.

Introduction

The home is quickly emerging as an important site of health care delivery and management1. Technologies in many forms are being developed to facilitate health-related tasks in this novel setting. In the last decade, patients and their caregivers have come to rely on multiple types of informatics applications including informational websites, patient-accessible electronic health records, and on-line communities2. It is imperative that patients and their caregivers are supported in the field as new models of care that incorporate these technologies are developed and deployed.

HeartCare II was a collaborative effort between an academic partner, the University of Wisconsin-Madison, and a clinical partner, Aurora Health Care, to design and deploy an innovative home-care nursing model, technology-enhanced practice (TEP)3. The technological core of TEP was a suite of web-based tools that provided patients with self-management information, self-monitoring tools, and messaging services to help them manage chronic heart disease in the home. The authors found that patients exposed to TEP demonstrated better quality of life and self-management of chronic heart disease during the first 4 weeks, and were no more likely than patients in usual care to make unplanned visits to a clinician or hospital4. Perceived usefulness of the technology accounted for 53.9% of the variability in behavioral intention, the measure used to determine technology acceptance5. This paper presents a case study within the United States of patients’ calls (or calls made on the patients’ behalf by a nurse or family member) to a service desk during HeartCare II, which was a large, 3-year, randomized field experiment implemented between August 15, 2005 and February 28, 2008 and involving 60 nurses and 282 patients3. The purpose of this analysis is to provide other deployers of home-based clinical information technologies with 1) an understanding of the types of support that were required during use and 2) implications of these needs for support during use.

To ensure effective use of the HeartCare II technologies, we invested significant resources in both the initial design of the technology and the support of its use. Optimal design of the technology was promoted through intense engagement with intended users throughout the design process3.

The HeartCare II study protocol permitted some choice in hardware and internet service: 1) those participants who did not own a computer were provided with a free, new Wyse thin client computer, monitor, keyboard, mouse, modem, 6 months of free dial-up internet connectivity and access to the HeartCare II web portal and all of its services; 2) those participants who owned their own computers but did not have Internet connectivity were provided with the modem, 6 months of free dial-up Internet connectivity, and HeartCare II access; 3) those participants who owned their own computers and paid for Internet connectivity were provided with only HeartCare II access. Home care nurses were educated to provide computer and website use training to all participants, regardless of the type of technology provided or used, during regular clinical visits to participants’ homes. All participants were provided with access to a 24/7 available commercial service desk to assure that they had access to technical help as needed.

To ensure quality technology deployment and function, one of the investigators (LJB) used a database throughout the study to track all service desk calls from initial call to resolution. Through analysis of all service desk calls, we now provide academic and industry designers with insight into the type and amount of aid requested by users and the implications of these requests for the deployment of future home-based clinical informatics technologies.

Background

A commercial model of technical support was chosen based upon our clinical partner’s need to create a system that would be sustainable following completion of the HeartCare II study. Our service desk system consisted of two tiers of service. The Aurora Health Care Service Desk, which provides telephone technical support for over 900 computer applications used by more than 18,000 clinicians at Aurora Health Care, provided the first line of support. If the Aurora Service Desk representative was unable to resolve the problem and it seemed to be related to hardware issues, such as the monitor, keyboard, mouse, computer, modem, or telephone internet connection, then the service desk representative initiated an email request for technical service to Paragon Development Systems (PDS), a commercial supplier. When the PDS Artie^SM Service Desk representative was unable to resolve issues via telephone, they assigned a field engineer to make a house call to troubleshoot the problem(s) later that day or the following day. Field engineers typically went on home troubleshooting calls carrying two complete new computer units and a toolbox stocked with 30- and 60-foot telephone extension cords, electrical power strips with 15-foot cords, splicers and other appropriate tools.

All Aurora and PDS Artie^SM Service Desk representatives were trained in the goals and procedures of the project and provided with written procedure manuals documenting solutions to commonly expected problems (e.g., forgotten passwords, how to turn on/off computer and monitor). They were also given copies of the written reference materials that were left at participants’ homes following study enrollment. In addition to this training, study investigators trained the PDS field engineers on safety procedures for working in participants’ homes, how to coach a participant to turn on the technology, and how to modify the computer screen font size to satisfy participant preferences. Supervisors from PDS provided the field engineers with training on procedures for pre-deployment testing, in-the-home installation, post-installation testing, trouble-shooting, reporting, technology-recovery, refurbishing, and inventory management.

Support for technology-related problems was available to participants through the Aurora Service Desk 24 hours a day, 7 days a week, including holidays. One supervisor and 19 full-time service desk representatives staffed the Aurora Service Desk. Service desk representatives consulted with additional technical support providers through a “hot pager call list” system if the problem could not be resolved at the service desk. Additionally, 1 supervisor and 3 full-time service representatives from the PDS Artie^SM Service Desk team were made available for HeartCare II support 12 hours per day, 5 days per week. PDS Artie^SM analysts also had automatic e-mail responders set up 24 hours per day, 7 days per week to acknowledge receipt of e-mailed service requests.

Methodology

A printed report was generated of all HeartCare II related calls made to the Aurora Service Desk. A second printed report of all calls transferred from the Aurora Service Desk to the PDS Artie^SM Service Desk and, if necessary, to the field engineers was also generated for the same time period. One investigator (LJB) maintained a database to trace the original call’s date, caller type, nature of the call, and interventions from initial request for assistance to final resolution. The interventions were linked between the two reports based on the participant’s name, date and nature of each call. Throughout the study, the investigator kept weekly surveillance on problem resolution and clarified additional needed interventions with appropriate service desk supervisors if a call was sub-optimally managed. At the end of the study, when data acquisition was complete, the investigator de-identified the data set and shared it with the academic partner for analysis. The Aurora Health Care Institutional Review Board granted expedited approval to conduct the HeartCare II study.

At the midpoint of the study, inductive coding6 was used to derive broad categories of problems faced by users of the HeartCare II technology7. Each call in the full data set was coded by two of the authors (RSV and BAS) into one or more of the specified categories: user, hardware, software, and/or internal communication. User problems stemmed from user’s lack of knowledge and not from a failure of the technology. Hardware problems were related to the physical equipment and Internet connection; software problems were related to the website. Finally, internal communication problems resulted from a failure in communication between service desk staff, computer consultants, Internet providers, research staff, and/or participants. Discussion and consensus building were used to resolve any differences of opinion as to where problems should be coded.

Further analysis of the service desk call database consisted of determining the volume of calls generated by HeartCare II participants for each of the service desks. Volume was measured by calculating the total number of calls generated by users over the life of the project, the number of unique callers, the average frequency and variability of calls per month, and the number of calls referred from the Aurora Service Desk to the PDS Artie^SM Service Desk.

Finally, by merging the service desk call database with a database from the main HeartCare II study, we conducted a detailed analysis of the demographic characteristics of service desk users. This analysis enabled us to determine the age, education, race, and computer equipment and experience of participants who called the service desk (or had someone call the service desk on their behalf). Furthermore, merging of these databases enabled us to explore potential differences between those who used and those who did not use the service desk.

Results

Two hundred eighty-two participants were recruited into the HeartCare II study; 146 of these participants were in the experimental group. During the study 51 unique users (35% of experimental participants) generated a total of 106 calls. Usage by any given participant varied between 0 and 7 calls.

Although the Aurora Service Desk received an average of 3.4 calls per month for the 31 months of the HeartCare II study, the actual number of calls each month varied from a minimum of 0 calls to a maximum of 12 calls per month. Of the 106 calls received by the Aurora Service Desk, 80 (75%) were referred to the PDS Artie^SM Service Desk. PDS received an average of 2.6 calls per month; in any given month the PDS Artie^SM Service Desk received between 0 and 10 calls.

Each of the 106 calls was assigned one or more codes based upon the text generated by service desk employees to document and describe each call. A total of 122 codes were assigned, illustrating that some calls bridged more than one problem category. Examples of calls in each category and the distribution of call across categories are shown in Table 1. A comparison of service desk users and non-users is shown in Table 2.

Table 1.

Number of Calls by Problem Categories

Problem Category	Description of Category	Examples	# of Calls	% of Total Codes N=122
User	User lacks required knowledge	Questions about how to use technology, Forgotten password	53	43%
Hardware	Problems with equipment & Internet connection	Problems with computer, modem, mouse, cables	38	31%
Software	Problems with the HeartCare II website	Problems loading website; Missing access to the HeartCare II website; Improper preferences and settings	19	16%
Internal Communication	Communication breakdowns among users (IT, vendor, research & clinical staff and study participants)	Problems with technical training; Problems with payment of internet bills after completion of study; Questions about after-study protocol	12	10%

Table 2.

Comparison of Service Desk Users and Non-Users

Users (N=51)	Characteristic	Non-Users (N=95)
65.0	Age in Years	63.8
12.7	Education (years)	14.9
56%	Non-White	28%
41.2%	High-speed Internet	74.2%
17.6%	Own Computer	70%
None-Beginner	Self-Rated Computer Experience	Beginner-Competent

Discussion

Analysis of the participants’ calls revealed a modest use of the service desks, with fewer than 40% of participants requesting help. Approximately one-third of all participants in the experimental group called the service desk; the Aurora Service Desk and PDS Service Desk received only 3.4 and 2.6 calls per month, respectively. The large proportion of calls referred to the PDS Artie^SM Service Desk and the large variation in number of calls received each month by both service desks, however, suggests that deployment of future home-based clinical informatics technologies must have a mechanism in place for responding to a potentially significant call volume and to calls that require significant time on an onsite visit to resolve.

Analysis of the user calls, which comprised half of all service desk calls, highlighted that not all participants understood the capabilities of, nor were comfortable using, the technology. Specifically, our finding that participants had difficulty using the password feature, which corroborates conclusions of previous studies8,9 suggests that future deployers should evaluate whether this level of access control is needed within the home or whether authentication can be created via an alternative means such as biometric authentication. Furthermore, although all nurses were educated using a train-the-trainer model10 on the use of the technology and how to teach the patient about technology use, it is evident that the training did not result in all participants’ being comfortable with the technology. One recently published study emphasizes the large amount of training that may be required for both nurses and chronically ill older adults to achieve comfort with technology11, suggesting that better methods of educating both nurses and patients are needed prior to future deployment of home-based clinical informatics technologies.

Analysis of internal communication calls revealed that the multiple groups that were involved in deploying and using the technology did not always communicate effectively. For example, telephone companies’ billing practices expected immediate payment while the technology deployment company had accounts payable practices that did not allow for payment within the telephone company’s expected timeframes. Consequently, a small group of participants’ Internet access was interrupted for one or two days until this problem was identified and an alternative payment process was created. Additionally, participants were not always clear as to what service could be expected following study completion, despite these services being clearly communicated in letters sent to the participants’ homes. Similar findings related to patient concerns about what services will be available in the future have been documented in previous health informatics studies12. These findings imply that groups deploying home-based clinical informatics technologies should carefully create and communicate protocols among entities both directly (e.g., caregivers) and indirectly (e.g., service providers) involved in deploying the technology in the field.

An analysis of service desk users and non-users points to potential predictors of the need for support. Multiple factors such as education, race, computer experience, and type of computer equipment and Internet connection may be correlated with service desk use. Particularly striking were differences in type of computer equipment, Internet connection, computer experience, and race. Traditionally, professional service desks such as those employed in this study are designed to serve professional clientele working in an organizational setting. Such users are likely to have a standardized and advanced form of computer equipment and Internet connection and are likely to have computer experience. Furthermore, such users may share a professional culture that guides the interaction with the service desk provider. In contrast, as found in our study, patients calling a service desk from home may not have access to advanced technologies nor computer experience. Patients calling from home may also be guided primarily by their personal cultural affiliations13, as opposed to a shared professional culture. For these reasons, service desk personnel must be trained to be sensitive and responsive to the diversity of individuals, calls, and contexts.

In this case study the patients and service desk were located within the same metropolitan area, allowing home visits whenever needed. In other industries, however, service desks are not always collocated with the individuals they are intended to serve14. Instead a service desk located in one geographical area may be able to serve users across the globe. Such a model would be desirable for supporting patients’ and their caregivers’ use of health IT, particularly to reach rural or developing areas in which technical expertise may not be locally available. However, as demonstrated in this work, such a model may need to be complemented with a “local expert” that would be trained and available to go into the field to solve problems requiring physical presence for resolution.

Conclusion

This study provides both a quantitative and qualitative analysis of service desk calls in a large home-based clinical informatics study. By using data that were obtained in a field instead of a lab-based setting, we were able to corroborate findings that substantiated previous guidelines from a new methodological angle and to provide new insights into the deployment of home-based clinical informatics technologies.