Progress toward contextualized, persuasive, and integrated consumer information technologies for health

In January 2019, during my first month as JAMIA Editor-in-Chief, I was the lead author of a paper published in the American Journal of Public Health that focused on consumer information technologies (CIT) comprising mHealth, telehealth, and social media and made recommendations for enhancing their contribution to advancing health equity.¹ Although the specific focus of the paper was behavioral interventions, I selected the 5 papers highlighted in this Editorial because they reflected several recommendations from the paper that are more generally relevant.

1. Intervention design should: (A) integrate methods that facilitate the alignment of intervention focus, CIT platform, and user characteristics such as cultural beliefs, preferences, and functional, digital, and health literacy as well as the ecological context of use and (B) incorporate mechanisms of action for behavior change and persuasive design principles to sustain user engagement with CIT-enabled engagement.

2. Advance multilevel interventions by linking mHealth and social media-based interventions with the healthcare system through electronic health record (EHR)-based approaches including clinical decision support, tethered patient portals, and clinical dashboards.

Choudhury et al² report the findings of quasi-controlled intervention to augment maternal health awareness among tribal pregnant mothers in India as a strategy for addressing maternal health disparities. The study provides an excellent illustration of addressing recommendation 1A.¹ They compared oral education delivered by Hindi-speaking community health workers (standard of care village) to standard of care plus mHealth (intervention village) in women (n = 740 in each group) from 2 independent villages with similar sociodemographics on awareness of selected maternal health concerns. These included danger signs of pregnancy (eg, vaginal bleeding, severe blurring of vision) as well as prevention strategies (eg, tetanus injection, iron tablet consumption). The community health workers also ensured ambulance availability if needed and financial incentives for women delivering at the hospital for both groups. The mHealth application comprised 4 modules (registration, antenatal care, intranatal care, and postnatal care) and was used by the women in the presence of the community health worker. Aspects of the application that supported low literacy users included photographs and voice prompts. There were significant differences between standard of care and intervention groups on all awareness measures although the control group also improved on most measures. The study did not report maternal health outcomes but demonstrates promising findings related to increasing awareness of maternal health topics among women with low literacy by augmenting a community health worker intervention with mHealth.

In a systematic review of 74 studies, Liu et al³ focus on user interface and persuasive design features in mHealth apps for older adults. While carefully considering user characteristics as in recommendation 1A, the review also highlights persuasive design features as emphasized in recommendation 1B.¹ The authors extracted and synthesized recommendations related to user interface considerations for older adults from the 74 studies into 3 categories; 4 recommendations targeted cognitive and memory deterioration (eg, simple and consistent layout, easy navigation), 3 targeted perceptual capability (eg, font, color, audio), and 2 targeted motor coordination (eg, use of simple gestures such as tapping, minimize text input). The authors also classified persuasive features identified in studies into 5 categories: reminders (n = 20), social features (n = 17), game elements (n = 7), personalized interventions (n = 13), and health education (n = 27). A total of 37 studies in the review addressed both user interface and persuasive design features, both critical to use of mHealth apps by older adults. The authors note the lack of application of theory in the selection of design features in all, but 5 studies reviewed. They also call for the evaluation of specific design features to augment overall evaluation to advance the knowledge base of what works for specific populations as well as more rigorous evaluation designs.

There is increased attention and federal requirements to the integration of a variety of apps including mHealth apps into electronic health record systems. Two papers in this issue address the topic of integration and address the second recommendation of Bakken et al.¹ Barker and Johnson⁴ summarized the ecosystem of apps and software integrated with certified health information technology through characterizing the app market by EHR app gallery and type of app; tracking changes in the EHR app galleries from the end of 2019 through 2020; and examining how apps connect to EHR data systems, and support for the Health Level Seven (HL7) Fast Healthcare Interoperability Resources (FHIR) standard. They developed a program that gathered data from the public app galleries hosted by Allscripts, athenahealth, Cerner Corporation, Epic Systems Corporation, and Substitutable Medical Apps & Reusable Technology (SMART). The functionalities of 734 apps discovered through this process were classified according to 5 categories: Administrative (42%), Clinical Use (38%), Care Management (31%), Patient Engagement (20%), and Research (5%); a single app could have functionality in multiple categories. Clinical and care management apps supported the FHIR standard at a higher rate than administrative apps. While not specific to mHealth apps, the types of apps in Care Management and Patient Engagement categories reflect tasks typically supported in mHealth apps such as disease management, care planning, medication management, and patient education. However, they note that their approach may not represent all apps integrated with the EHRs. In particular, patient-facing apps may be more widely marketed in smartphone app stores, such as the Apple or Google app stores.

Rudin et al⁵ sought to determine EHR integration requirements for a scalable remote symptom monitoring intervention for asthma patients and their providers. Guided by the Non-Adoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework, they conducted a user-center design process with English- and Spanish-speaking patients as well as providers. Methods included: secondary analysis of interviews (n = 26) conducted for a previous feasibility study, design sessions (n = 21), and a primary care provider (PCP) survey (n = 55). In addition to functional requirements for the technology (patient app and provider dashboard), workflow needs of nurses and PCPs, and high-level user interface design needs for the purpose of collecting patient-reported outcome (PRO) data and monitoring asthma symptoms between visits, they identified 3 EHR integration requirements. First, to support PCPs access to the asthma PRO dashboard via a navigation bar from patient charts before or during a visit, the third-party application needed to be registered as an EHR extension. Second, a data services application programming interface was required to send EHR inbox notifications to nurses and PCPs for patient callback requests and previsit reminders. Third, to send previsit tips to patients and reminders to PCPs, the application required access to visit schedules and the identity of the PCP. While the authors implemented custom solutions to meet these EHR integration requirements due to existing expertise, they plan to explore FHIR as a future solution.

Reflecting consideration of the ecological context of use (recommendation 1A),¹ Alford-Teaster et al⁶ developed a measure of geographic access to telehealth to enable assessment of the contribution of telehealth access to alleviating the disparities in healthcare access in rural areas and for disadvantaged populations. The 2-step virtual catchment area (2SVCA) method is an enhancement to the standard 2-step floating catchment area (2SFCA) method. 2SVCA considers durability and speed of broadband access. They demonstrate the use of the measure through a case study of Vermont showing an increase in access as measured by 2SVCA as compared to 2SFCA. While appropriately acknowledging several limitations of their method, the authors argue that such a measure will enable policy analysis to assess the impact of the dramatic shift in increase of telehealth services and address questions such as: Will telehealth close the gaps or enlarge the divides? What policy or strategy can effectively mitigate any negative outcomes of telehealth while preserving and enhancing positive gains?

Although the highlighted studies reflect a very small sample of the research being conducted and much remains to be done, such studies suggest that there is progress in contextualization, inclusion of persuasive design features, and integration of CIT with EHRs.

CONFLICT OF INTEREST STATEMENT

None declared.