HeartCareII: Patients' Use of a Home Care Web Resource

Abstract

In a six-month randomized field experiment our team evaluated the impact of a technology-enhanced practice (TEP) model compared to the usual care delivered by home care nurses. Research staff provided computers and technical assistance; home care visit nurses trained patients in the use of the components of the HeartCareII websjte most relevant to their care needs. The purpose of this paper is to explore participant exposure to the web-based HeartCareII resources, the technical core of the TEP. To assess exposure to the HeartCareII resources we counted logins, the number of accesses to the system, over each participant's study period. We determined that more logins occurred during the first four weeks of the participants' time in the study, with 50 percent continuing to logon after 4 weeks. The number of participants accessing the system declined during the ensuing weeks to approximately one-third at eight weeks; almost 15 percent consistently logged in throughout their 24-week course in the experiment. This pattern of exposure to such web-based resources is consistent with findings of prior studies; it may support an episodic need for health resources in the home based on changing health demands.

Introduction

Consumer health informatics (CHI) initiatives include health related websites, patient portals, and more recently, personal health records that provide individuals with tools and actionable information to monitor and manage their health. They are aimed at enabling patients to make better health care choices and more effectively participate in health care, and may have their greatest effect if they are well-integrated into specific patient care services. Patients with chronic heart disease may benefit from such specially-designed, multiple service web-based informatics tools that have the potential to support, augment and extend the in-home health care services provided by visiting nurses. Unlike previous CHI experiments conducted by our group [1,2] which delivered web-based in-home support services directly to patients, the HeartCareII project situated a specially-designed web-based resource for patients as an integral component of a home care nursing practice. Thus, investigating how and when participants accessed the technical core of our intervention helps characterize innovative nursing practices, supported by computer technology.

We envisioned Technology Enhanced Practice (TEP) as a model of home care nursing comprised of three key components: professional nursing practice, patient self-monitoring and self-management, and web-based support. We anticipated that the nature of TEP would vary with the nurses' assessment of patient needs, skills and preferences as well as the nurses' practice styles. Design of, and nurse training in use of the resources were based on the premise that at times nurses might implement more in-person intervention supported or augmented by less use of technology; other times the web-based coaching, self-monitoring and communication tools could supplant traditional in-home care.

Quantifying exposure to such tools becomes increasingly important and challenging with the emergence of diverse, interoperable personal health applications of multiple-purpose personal health record systems. Yet doing so is a necessary first step towards determining subsequent effects of innovations in care; thus in this study, decisions about defining and quantifying exposure to the resources were guided by Brennan's 4-S framework [3] which is based on evaluation of system, service, session and subject levels of use.

1. Objective

The goal of the HeartCareII project was to develop and test a sustainable model of home care nursing supported by a technology core and home based technology. The major aim of the HeartCareII project was to examine the impact of TEP on chronic heart disease patients' outcomes including stabilization of functional status, improved quality of life and satisfaction with care while reducing service utilization. The purpose of this paper is to explore participant exposure to the web-based HeartCareII resources.

2. Materials and Methods

2.1 The Technology Core: The HeartCareII Resources

The first phase of the study focused on the design and development of the HeartCareII technical core; details of this phase are reported elsewhere[4]. The technology core for TEP was based on the existing nursing practice model for patients with chronic heart disease; it was designed to support, augment and expand nursing work and to facilitate patient self-monitoring and self-management.

The HeartCareII website provided a standard suite of technology services which nurses individualized for patients based on their needs and illness trajectory. The HeartCareII website was housed within the clinical partner's patient portal; it could be accessed by both nurses and patients through an internet connection. This allowed access from a variety of settings including point of care, VNA office, cardiac rehabilitation centers, or family members' homes. The HeartCareII website included tracking tools (e.g. weight, blood pressure and heart rate), symptom monitoring, information (e.g. agency standard patient education tools and vendor developed disease and medication sources), and communication (e.g. secure messaging with VNA nurses and a bulletin board).

Logins to the HeartCareII website were collected through a passive monitoring system within the institution's patient portal; it incremented by one each time a patient logged in (successfully entered their username and password) to the HeartCareII home page. Since our concern was the individual's exposure to the resources, we used number of accesses to the website as the metric for exposure. This metric provides the best available estimate of exposure; other investigations are needed to explore behavioral indicators of use and link actions to clinical outcomes. [3,6,7].

2.2 Usual Care and Technology Enhanced Practice

Nurses visited the study participants 2 to 9 times during their allocated home care service. Nurses encouraged patients to explore the website on their own and recommended use of pertinent tools based on patient needs. Additionally, patients could exchange secure messages with their nurses and communicate with other study patients through the HeartCareII bulletin board.

As part of the patient admission procedure, nurses completed the VNA intake protocol and conducted an information needs assessment. They used this information to plan the patient's TEP intervention, to identify interventions and select HeartCareII resources for the patient. If the nurse appraised a patient's information needs as high, he or she encouraged the patient to use specific information resources to provide ongoing, between-visit education. If the nurse identified that the patient had strong needs for coaching and support, they could use the secure messaging service for more frequent communication. The chronic heart disease protocol also required patients to weigh themselves daily; nurses directed patients to the weight tracker to record their weights. Recommendations for patients' use of the HeartCareII resources related to type of service, frequency, and duration varied across nurses based on patients' needs and abilities as well as nurses' levels of clinical expertise, preferences, and experience with technology[5]. Nurses used professional judgment to individualize TEP.

2.3 Conduct of the Experiment

This multiyear project, conducted within a large integrated health care delivery system, involved five VNA offices, approximately 80 home care nurses, and 282 patients with chronic heart disease. The majority of nurses were female; with an average age of 43 years old (range 24-60); and racial composition was predominantly Caucasian. Although all nurses used laptop computers with proprietary software for planning and documenting the care they provided, they exhibited substantial variation in their comfort and skill in using the HeartCareII technology core.

The five VNA offices were randomly assigned to either the experimental (TEP) group or the comparison (usual care) group. Following written consent to participate in the study, patients were informed of their group assignment. Participants with their own computers had them configured for the study; otherwise, research staff provided patients with a computer and basic instructions on its use. During the first visit after installation of the computer or HeartCare icon, home care nurses integrated the HeartCareII resources into each patient's individualized plan of care. Details about the comparison group will be reported elsewhere.

3. Results

3.1 Sample

In the 30 months of the experimental phase of the project, 282 patients were enrolled; 146 of these received TEP care. Patients in the TEP group ranged in age from 28 to 93 years old; mean age was 64 (S.D. 12.5). There were 86 males and 60 females in the sample. The majority of the participants (78%) were Caucasian, 13% were African American, 5% multiple races and 4% other. Mean education was 14 years (S.D. 3.97). Of the 146 participants, 61% were married and 84 % lived with someone. Seventy patients (49%) had a primary diagnosis of congestive heart failure (CHF); 51% were recovering from cardiac surgery. Seventy-four (51%) used varying configurations of their own computer; 70 (49%) used a computer provided by the study. Self-reported computer experience also varied: 19% reported no experience; 35% identified as a “beginner”, 38% as “competent”; and 8% as “expert”. Of the 146 enrolled participants, 117 completed their entire 24 weeks of the study; reasons for non-completion included death, withdrawal, and lost to follow-up. Because we will take an intention to treat approach to outcome analysis, all participants' data were included in the analysis of technology exposure.

3.2 Exposure to HeartCare Resources: Counts of Logins

Patient exposure, measured by the number of logins to the HeartCareII website, ranged from 0 to 314 over the participants' study periods. The mean number of logins was 19 (S.D. 40.6). As illustrated in Figure 1, about 50% of participants continued to login to the HeartCare II website for four week and this declined to 33% at eight weeks while 15% continued to login for the 24 week duration of the study.

Figure 1. Persistence in Logins.

Previous explorations of participant characteristics have documented that there are no substantive differences in login behavior between patients who had a primary diagnosis of heart failure and those who were recovering from cardiac surgery. Nursing care guidelines and illness trajectory are different between the participants with chronic heart failure and post surgical patients as is their length of exposure to home care service; more than three weeks compared to 1-4 visits, usually spanning about a week for the groups respectively. Similarly, neither self-rated computer experience (none through expert) nor owning a computer vs. using a study-provided computer appeared to impact the number of logins to the HeartCareII website.

4. Discussion and Conclusions

The results of this exploration of exposure to the HeartCareII resources confirmed that patients with chronic heart disease will use a web resource during and after the home care phase of post hospitalization health care services. The observed variability in access to the HeartCareII resources follows patterns of use that parallel those found in earlier studies [8-10]. They provide evidence supporting patients' active engagement in web-based information and use beyond the initial home visit phase, suggesting that this informatics tool has the potential to extend nursing care impact. Through this study, in which the HeartCareII resource was designed to support, augment and extend formal nursing services, we provide the first benchmarks to estimate how often a patient is likely to access the system or to persevere in its use.

Patient characteristics did not explain variation in number of logins or persistence in exposure. It does not seem likely that reason for VNA service, computer experience or access device influenced login behavior. The data indicate that these factors alone are insufficient to explain use of the HeartCareII resources.

Several factors or a combination of factors may explain the observed variability in use of the HeartCareII resources. Patients are known to have greater needs for support and information following hospital discharge; this may explain our observation that proportionately more logins occurred in the participants' first four weeks. Although the duration of home care was less than 4 weeks for at least half of the participants, nurses may have influenced early use. Alternatively, the comparable use to previous studies may suggest that nurse involvement in this study had little impact on patient use behaviors.