Page 2 of 22 - Selfback › uploads › 1 › 0 › 7 › 1 › 107154065 › d4_3_sp… · Page 5 of 22 D 4.3: Clinician Dashboard Design (SPECW) SELFBACK Dissemination Level: CO

Projectno:689043Acronym:SELFBACKTitle:Adecisionsupportsystemforself-managementoflowbackpainActivity:PHC-28-2015PredictivemodellingRIA

ThisprojecthasreceivedfundingfromtheEuropeanUnionHorizon2020researchandinnovationprogrammeundergrantagreementNo689043.

WorkPackage4: UserInterfaceandInteractionDeliverableD4.3: SpecificationandDesignDocumentfor

theClinicianDashboardOrganisationnameofdeliverablelead: NTNUAuthor(s): KerstinBach,CindyMarling,PaulJarle

Mork,BarbaraNichollReviewer(s): MetteJensenStochkendahlParticipants: NTNU,GLAType: ReportDisseminationLevel: PUVersion: 1.0Totalnoofpages: 22ProjectStartdate: 1.January2016Contractualdeliverydate: 31.December2016Actualdeliverydate: 30June2017Keywords: ClinicianDashboard,Specificationand

Design,Co-DecisionModuleStatus: Submitted

Abstract Thisdeliverabledescribesthespecificationandinitialdesignofacliniciandashboardthatfacilitatestheco-decisionmakingbetweenthepatientandtheclinician.Itcoversthepurpose,functionalspecificationsanddraftsoftheweb-frontendofthedashboard.Thedocumentalsodescribespersonasofaclinicianandpatienttoexemplifyhowthedashboardcouldbeusedinpractice.

Page2of22

D4.3:ClinicianDashboardDesign(SPECW) SELFBACK DisseminationLevel:CO

DocumentHistoryVersion Date Author(s) Description0.1 14/05/17 KerstinBach Initialversionofthedocument0.2 24/05/17 KerstinBach Addedtailoringcontentandscreens;extendedsection

1:objectives0.3 26/05/17 BarbaraNicholl Addeddescriptionofpersonas0.4 01/06/17 PaulJarleMork Addedtexttointroduction

RevisedobjectivesMinorchangestofunctionalities

0.5 13/06/17 KerstinBach Addedwireframesandexplanationstothescreens0.6 14/06/17 PaulJarleMork Addedchapter6:Co-decisionanddecisionsupport

systemsinclinicalpractice0.7 21/06/17 BarbaraNicholl Addedpotentialconversationtopicsandsynopsisof

clinicalguidelinesupdateongroupmeeting21.6.170.8 29/06/17 KerstinBach RevisedversionafterreviewfromMetteJensen

Stochkendahl1.0 30/06/17 KerstinBach FinalversionsubmittedtotheEC

Page3of22


TableofContents1 Introduction 41.1 Co-decisionanddecisionsupportsystemsinclinicalpractice 51.2 Objectives 5

2 Specification 62.1 Functionalities 62.1.1 RestrictionsforCo-DecisionMaking 7

3 Input 8

4 Wireframes 94.1 Startingpage 94.2 Retrievepatientdata 104.3 Dashboard 114.4 TileExample:PhysicalActivityHistory 124.5 TileExample:PhysicalActivityGroupComparison 134.6 Exampleadditionalinformationforclinician 15

5 Co-DecisionMaking:Clinician–Patientinteraction 17

6 Personas 186.1 Patient 186.2 Clinician 18

7 TheimplementationoftheSELFBACKClinicianDashboardinClinicalPractice 207.1 Patientgenerateddata 207.2 Barriersforimplementation 207.3 Exploitationofthecliniciandashboard 217.4 SummaryandFutureWork 21

Page4of22


1 IntroductionSELFBACKprimarilytargetsthepersonalisedself-managementoflowbackpain(LBP)forpatients,butwillalsoshowcaseordemonstratehowtheoveralldatafrompatientscanpotentiallyhelpinco-decisionmakingbetweenthepatientandtheclinician.Figure1illustratesthedataprocessingintheSELFBACKsystemandhowthepatient-directedmoduleslinkwiththeco-decisionmodule.Thepatientwillregularlyscorepainandfunctionalabilityintheapp(module3).Thesedatacan,withpermissionfromthepatient,besharedwithcliniciansasinputtotheco-decisionmodule(5).Inaddition,thephysicalactivitydatacollectedbytheactivity-detectingwristbandandtheself-managementplanscanalsobemadeavailabletotheclinicianwithpermissionfromthepatient.

ThecaptureddatamayprovidevaluableinsightfortheclinicianwhenapatientseekshelpforLBP.Inthedecisionsupportsystemoftheco-decisionmodule,thehistoryofoneparticularpatientcanbecomparedtothehistoriesandoutcomesofsimilarpatientsandcanbeusedtosupportdecisionsaboutthepatient’streatmentplan.Thisinsightwillpositiontheprogressofsymptomsofthepatientinalargepatientpopulationandhelpthecliniciantodecideaboutfurthertreatment.Furthermore,thisinformationcanassisttheclinicianinmakingdecisionsaboutreferraltospecialisthealthcareforfurtherinvestigation.Eventually,itmayalsoaidindecisionmakingforgrantingofsicknessleaveandprescriptionofmedication.

Figure1.IllustrationofthedataprocessingintheSELFBACKsystemandhowthefourpatient-directedmodules(1-4)andtheoneco-decisionmodule(5)linktogether.

Page5of22


1.1 Co-decisionanddecisionsupportsystemsinclinicalpractice

Ithasbeenover50yearssincethefirstclinicaldecisionsupportsystems(CDSSs)wereimplemented.Historically,thesesystemswerebuilttoassistclinicianswithvarioustasks,suchasdiagnosis,therapyplanningandcritiquing,drugprescription,informationretrieval,andimageinterpretation.Theyhaveprovidedremindersofpreventivemeasures(e.g.,prescribingantibioticsbeforesurgery)andalertsaboutpotentialdangers(e.g.,adversedruginteractions)[7].Traditionally,ithasbeenassumedthatthehumandecisionmakerusingtheCDSSisaphysician,althoughsometimes,othercliniciansaresupportedaswell.ClinicianresistancetotheuseofCDSSshasbeenalongstandingproblem,withtechnical,institutionalandculturalbarrierstosystemadoption[8].TheuseofCDSSsbypatientsisarelativelyrecentdevelopment.

Overthepastdecades,healthcaresystemsandpoliticianshaveplacedincreasingimportanceontherelationshipbetweenpatientchoiceandclinicaldecision-making[7].Suchco-decisionorshareddecisionmakinghasbeendefinedas:“anapproachwherecliniciansandpatientssharethebestavailableevidencewhenfacedwiththetaskofmakingdecisions,andwherepatientsaresupportedtoconsideroptions,toachieveinformedpreferences”[7].Thus,bypromotingshareddecision-making,patientsareencouragedtoassessthebenefitsandrisksofdifferentavailabletreatmentormanagementoptions.Thiswillincreasepatientengagementandensurethatpatientautonomyisrespected.Tofacilitateshareddecision-making,thepatientandcliniciancanutilisedifferent‘decisionaids’,e.g.,customisedsoftwarethatcanaggregatecurrentbestevidenceandinformtheprocess.IBMWatsonisprobablythemostwell-knownrecentexampleofcomputerizedassistanceforclinicaldecision-making.1However,despitethefocusonandinterestintheuseofcomputerizedassistanceandshareddecision-making,implementationinclinicalpracticehasproveddifficult[7,8],andseveralchallengesremaintobesolved.

1.2 Objectives

TheSELFBACKprojecttargetsthecliniciansinprimarycare,includinggeneralpractitioners(GPs),physiotherapists,andchiropractors.Theobjectivesofthecliniciandashboardareto:

1. facilitateco-decisionaboutthetreatmentandespeciallytheself-managementplanbetweenthepatientandtheclinician

2. facilitatediscussionaboutbarriersand/orexpectationsforself-management3. helpthecliniciantoreinforceSELFBACKadviceandself-management4. providedatathatcaninformtheclinicianabouttheeffectofthecurrent

approachandfacilitateconsiderationofothertreatmentoptionsorreferraltospecialisedcareifdeemednecessary

1https://www.ibm.com/watson/health/

Page6of22


2 Specification

2.1 Functionalities

InaccordancewiththeHONcode2principle,theSELFBACKsystemisnotintendedtoreplacetheclinician-patientrelationship.Rather,itfacilitatestheclinician-patientrelationshipbyenablingthecliniciantoworkjointlywiththepatienttoreviewprogressanddevelopeffectivepainmanagementplans.TheclinicianapplyingtheSELFBACKapproachisequippedwithaweb-baseddashboardtobeusedforco-decisionmakingwiththepatient.TheSELFBACKserverisaccessedviaasecureconnectionthroughthiswebinterface.ItwilltypicallyberunonaPCandcanthereforedisplaymorecomprehensiveinformationthantheapp.Thewebinterfacewillbeabletodisplaystatisticson1)symptomsprogression(e.g.,pain,function),2)physicalactivitylevel,and3)adherencetoexerciseplansfortheconsultingpatientandsimilarpatientsundertreatmentorfollow-upbytheclinician. TheuseofSELFBACKisinitiatedwhenaclinician(aGP,physiotherapist,orchiropractor)refersapatientwithLBPtothesystem.Thisreferralassociatesthepatientwiththepracticeandlimitsaccesstothepatient’sdatatocliniciansinthepractice.Theclinicianlogsintothesystemwithausernameandpassword.Theclinicianonlyhasaccesstodetaileddataforpatientsinhisorherownpracticewhoconsenttodatasharing.Tomaintaintheprivacyofpatientdata,auniquepatientIDisgeneratedforeachpatienteveryweekandprovidedtothepatientviatheapp.DuringaconsultationthepatientsharesthiscurrentweeklyIDwiththecliniciantoenabledataaccesstoallthepatient’sdata,includingallhistoricdataaboutthepatient,forthedurationofthatweek,viathecliniciandashboard.OnceanewweeklyIDisgenerated,thecliniciancannolongeraccessthepatient’sdata,untilandunlessthepatientsharesanewIDduringasubsequentconsultation.Thetimingofconsultationswillbedependentontheparticularpatientneedsandclinician’spractice.ThepatientmaychoosetosharetheirIDwithmorethanoneclinician,e.g.,theirGPandtheirphysiotherapist.

Forco-decisionmaking,theclinicianlogsintothesystemwiththeIDprovidedbythepatientandthenaccessesdataforthatindividualpatientduringtheirappointment.Thisenablestheclinicianandthepatienttoreviewanddiscussthedatatogether.Becauseappointmentdurationislimited,thedashboardhasasimpleandintuitiveinterfacethatquicklyfocusesusersinonproblemsthatwarrantmutualdiscussion.Asillustratedwithwireframesinthenextsection,aninitialscreengraphicallydisplaysthepatient’sprogresswithrespecttophysicalactivity,exercise,sleep,function,pain,painself-efficacy,fearavoidance,andmood.Thishelpstoclarify,ataglance,whichaspectsofself-managementareprogressingwellandwhicharenot.Userscanthenchoosetoclickononlythoseaspectsthatarenotprogressingwellforadditionaldetailthatmayhelptoinformco-decisionmaking.Uponclicking,detaileddataforthepatientisdisplayedovertime.Forsomeco-decisionitems,whereanexternalreferencecouldbehelpful,thereisanadditionalplotofthe

2http://www.hon.ch/HONcode/Patients/method.html

Page7of22


patient'sprogressincomparisontothatofareferencegroupofsimilarpatients(e.g.,physicalactivity).Furtheron,eachplotisprintable,sothatthecliniciancanofferthepatienttocreateaprintout,whichthepatientcantakehome.Theprintoutwillonlycontaintheannotatedplot,butnofurtherpatientinformation.

2.1.1 RestrictionsforCo-DecisionMaking

Thefollowingrestrictionsarekeytoensuringpatientprivacyanddataconfidentiality.First,clinicianscanonlyseedetaileddatafortheirownpatients.ThisisenforcedthroughindividualweeklypatientID's,whichmustbeexplicitlysharedbypatientswithclinicians.Second,whendataisshared,theclinicianisonlygrantedaccesstothedatafor,atmost,oneweek.TheappprovidesanewIDtothepatienteachweek,alongwiththeirweeklyself-managementplan.Theclinician'sdataaccessautomaticallyexpireswhenanewIDisissued.Third,aggregateddataforprogresscomparisonmustcomefrompatientgroupscontainingatleast10patients.Thisistoensurethataggregateddatacannotbetracedbacktoanyindividualpatient.Theaggregateddataisonlyusedforreferencesothatthepatientcangaugehisorherprogressagainstthatofsimilarpatients.Similaritymeasureswillbetailoredtoselectsimilarpatientsforinclusioninthereferencegroups.

Page8of22


3 InputTheco-decisionmodulethatfeedsthedataintothedashboardisbasedonservicesthatwillusethesamedatasourcesastheapp,butaggregateandpreparethedatadifferentlyinordertodisplayhistoricaldataandtoidentifysimilarpatientsorgroups.Thegoalofthedashboardistocreateatoolforthecliniciantoeasiercommunicatetreatmentgoals.

Informationaboutthepatient–mostlyfocusingontailoringandself-monitoring:

• PhysicalActivity(Activityvs.Inactivity)• Exercise• Sleep• Function(Patientspecificfunctionalscale(1item))• Pain(Numericalpainratingscale(1item))• Painself-efficacyquestionnaire(2items)• FearAvoidance(Tampa(1-item))• Mood(PatientHealthQuestionnaire(2items))

Page9of22


4 WireframesInthissection,wewillpresentwireframesthatdescribethegeneralconceptofthecliniciandashboard.Figure1showstheflowthroughthedashboardduringaco-decisionsessionbetweenaclinicianandapatient.First,theclinicianhastologontothedashboard.Then,heorshehasaccesstodataforallofthepatientsassociatedwithhis/herpractice.Inordertoobtainapatientdashboard,thepatient’sIDhastobeentered.ThepatientcanfindtheIDintheSELFBACKapp.Next,thedashboardopenswithageneralviewprovidingpatientdetailsaswellasasetofninetilesfornavigatingthroughthesystem.Sub-pagescanbereachedfromeachtile,aswellasfromthenavigationpanel.

Figure1:OverviewoftheflowthroughtheClinicianDashboard

4.1 Startingpage

Thecliniciandashboardisonlyaccessibleforregisteredusers.Therefore,auserhastosignin,beforeaccesstothedashboardisgranted.Figure2showstheloginpageforthecliniciandashboard.

Page10of22


Figure2:Sign-inpage

4.2 Retrievepatientdata

Apatientisexpectedtousetheappsettingsandshowthecliniciananaccesscodetohisorherlatestdata.Thisaccesscodewillpullthelatestinformationfromtheserverandpresentittotheclinician.Figure3showsthe“home”pagefromwhichthecliniciancanstarttheco-decisionsession.

Page11of22


Figure3:Fetchingpatientdata

4.3 Dashboard

OnceavalidpatientIDfortheclinician’spracticeisentered,thepatientviewopenswithanoveralldashboard.Thedashboard,asshowninFigure4,containsfourcomponents:

• Theheaderdisplayingthenameoftheclinician.• Anextendednavigationbarontheleftwithaccesstoallsub-dashboards.• Apatientsummarydisplayingpatientspecificinformation.Thisinformationisused

forcomparingpatientsinthebackground.• Anoverviewofpatientgenerateddataindicatinghowfrequentuserdatahasbeen

provided.• Themainscreencontainingninetiles.Eachtileaddressesoneco-decisionfield.

Additionally,eachfieldhasabarontopindicatingthestatusofthepatientinthisfield.Green(6-8filledblocks)indicatesgoodprogress,yellow(3-5filledblocks)indicatessomechallenges,andred(1-2filledblocks)indicatesastrongneedforanintervention.

Inordertostartthediscussionwiththepatient,theclinicianhastoclickonthetiletoopenthenextscreen.Eachtilehasaquestionmark,whichlinkstofurtherinformationontheco-decisiontopicsandsummariesofclinicalguidelinesforthatparticulararea.

Page12of22


Figure4:ClinicianDashboardMainPage

4.4 TileExample:PhysicalActivityHistory

Onceaco-decisiontilehasbeenselected,moredetailedinformationisdisplayed.Inthehistoryview,theachievementofthephysicalactivityisdisplayed(Figure5).Itshowstowhichdegreethegoalshavebeenachieved.Thehistoryviewincludesthebaselineandthefirstthreeweeksaswellasthemostrecentweeks.ThebaselinedescribestheinitialnumberofdailystepsthepatientisabletodowhenenteringtheSELFBACKprogram.Thedashedlineinthemiddleindicatesthattheviewcanbeexpandedtoincludemoreweeksifdesiredduringtheco-decisionsession.Thisviewkeepsthepatientsummaryinplaceandonlyupdatesthecenterscreen.Further,thelinksontheleftstayinplace,sothecliniciancaneithergobacktothehomescreenormovedirectlytooneoftheotherco-decisionitems.

Page13of22


Figure5:HistoryView-PhysicalActivityExample

4.5 TileExample:PhysicalActivityGroupComparison

Inthegroupcomparisons–asdepictedforphysicalactivitiesinFigure6–weusethecurrentpatientandretrievesimilarpatients’casesfromthecasebase.Thesetofmostsimilarpatientsisthenusedtodefinetheminimumandmaximumachievementsinordertoshowhowtheachievementsofthecurrentpatientcomparetothoseofsimilarpatients.Thisretrievalonlyusescaseswithpositiveoutcomesfromthecasebase,therebyprovidinganargumentationguidelinethat,ifthepatientiswithintheboundaries,weforeseeapositiveoutcome.Ifthepatientisabovethemaximumforhis/hergroup,thisprovideseitherverypositivefeedbackforthepatient,providedotheraspectsoftheirself-managementplanarealsodoingwellorfeedbackisgiventhatthepatientisoveractiveandshouldtrytocomplywiththegivenself-managementplan.Ifthepatientisbelowtheminimum,theclinicianshouldaddressthat.Likewise,ifthepatientisveryactiveandsymptomsstillarehigh(e.g.,pain),itmaybethatthepatientisover-doingandshouldreducetheactivity.Inordertoachieveapositiveoveralloutcome,thepatientshouldtrytoadheretotheself-managementplansascloselyaspossible.

Page14of22


Figure6:GroupComparisonView-PhysicalActivityExample

Page15of22


Figure7:HistoryView-Moodvs.PhysicalActivityExample

4.6 Exampleadditionalinformationforclinician

Thecontentandself-managementplansoftheSELFBACKdecisionsupportsystemaredevelopedfrominternationalclinicalguidelines.InordertoensurethattheclinicianhaseasyaccesstosuchguidelinestheywillbeavailableviatheClinicianDashboard.However,thesedocumentsarelengthyandarenotnecessarilysuitableforconsiderationduringatime-limitedpatientappointment.ToprovideGPswiththesummaryrecommendationsfromtheseguidelinesthereis aoneachtile.Hoveringoverthisareawiththecursorwillbringuparecommendationfromthisareabasedontherespectivenationalguidelines,whicharemandatedbythenationalhealthauthorities(e.g.NICEclinicalguidelines3).Examplesfromfunction,exercise,moodandeducationmodulesare:

• Functiono EncourageapatientwithLBPtocontinuewithnormalactivities;including

returningtoworkornormalactivitiesofdailyliving

3https://www.nice.org.uk/guidance

Page16of22


• Exercise

o Takepeople’sspecificneeds,preferencesandcapabilitiesintoaccountwhenchoosingtypeofexercise

o Biomechanical,aerobic,mind–bodyoracombinationofapproaches• Mood

o Considercognitivebehavioralapproachesbutbestwhencombinedwithotherself-managementapproaches

o Encourageacombinedphysicalandpsychologicalprogrammeo ThePatientHealthQuestionnaire(2-item)hasbeenusedinSELFBACK,scores

of≥3suggestfurtherinvestigationmayberequired• Education

o ProvideinformationonthenatureofLBPo EnsuringthattheLPBisnon-specificandrulingoutcancer,fracture,infection

orinflammatorydiseaseprocesso Reassure–non-specificLBPislikelytohaveagoodoutcome;butyoucanalso

“livewell”withLBPo Importanceofself-managemento Ensureadviceandinformationistailoredtoindividualneedsandcapabilities

Page17of22


5 Co-DecisionMaking:Clinician–PatientinteractionBasedontheinformationavailableviatheSELFBACKClinicianDashboard,itisexpectedthatthiswillfacilitatediscussionbetweenclinicianandpatient,particularlyaroundwhatbarriersmaybepreventingpatientsfromengagingwithalloftheself-managementadviceprovided.Thefollowingarescenariosfromthedashboardthattheclinicianmightconsiderinstigatingaconversationwiththepatientabout:

• Thepatientisnotreachingtheirnumberofstepsgoal:o Whymightthisbe?Aretherewaysthatthiscouldbeovercome?Doesthe

patientunderstandthebenefitsofactivity?• Thepatientisachievingtherecommendedgoalofactivitybuttheirmoodisnot

improvingo Whymightthisbe?Hasthepatienttakenpartintheeducationalcomponent

ofSELFBACK?Doestheclinicianneedtoinvestigatethepatient’slowmoodsymptomsinmoredetail?Isthepatientdoingtoomuchactivity,couldtheyconsiderpacingtheiractivity?Isthereadifferenttypeofactivitythatthepatientmightprefer?Arethereotherproblemsthatmightbeeffectingtheirmood?

• Thepatientisachievingtherecommendedgoalofactivitybuttheirfunctionisnotimproving

o Whymightthisbe?HasthepatienttakenpartintheeducationalcomponentofSELFBACK?Aretheydoingthestrength/flexibilityexercisesaswellasthewalking?

• Thepatientisnotachievingtheiractivitygoalandtheirmoodandfunctionisalsopoor

o Hasthepatientbeenengagingwiththeadvicegiven?Couldtheyconsidersmallstepstowardstheirgoalandconcentrateontheeducationalcomponent?Doestheclinicianneedtoconsiderseeingthispatientmorefrequentlyuntilsymptomsimprove?

Page18of22


6 PersonasHerewehavedescribedtwopersonas–onepatientandoneclinician-toshowhowweenvisagetheClinicianDashboardbeingusedineverydaypractice.

6.1 Patient

Afemalepatient(age38years,bodymassindex31kg/m2,cleaner)wasadvisedbyherGPtostarttousetheSELFBACKtooltohelphermanageherLBP.ShehashadherLBPforalmostsixmonthsanditdoesn’tseemtobegettinganybetter.ShehasalwaysfoundthatwalkingmakesherLBPworseandbelievesshegetsenoughactivityfromherjobasacleaner.Shereportsusingoverthecounterpainkillerstohelphertobeabletodoherjobandshereportslowqualityoflifeassheisunabletoenjoyactivitieswithfriendsandfamily.ShehasbeenusingtheSELFBACKtool,wearingthewristbandandusingtheappforonemonth,shesaysthatshehasbeenfollowingtheadvicebutisnotabletoachievethestepsgoalsbecauseitaggravatesherpain.ShewantstodiscussherLBPwithherGP.

TheGPisabletobringupherSELFBACKprofileonthecomputeraftershegivestheGPherIDfromtheappandtheycanlookatthecomputerscreentogether.Thepatientfindsthisusefulandcanseethatsheisgraduallyincreasingthenumberofstepsthatsheistakingandisgettingclosertoherfirstgoal.TheGPstartstotalktoheraboutwhatitmightbethatisstoppingherfromdoingmoreexerciseandheshowshersomegraphsonthescreen.HerbeliefthatexercisewillresultinpainhasremainedconstantoverthepastmonthandtheGPsuggeststhatshewatchsomeoftheeducationalvideosontheSELFBACKappagaintotrytounderstandmoreaboutthecausesofLBPtoseeifthatmighthelphertrytodomorewalking.TheGPsuggeststothepatientthattheexercisewouldbehelpfulnotonlyforherLBPbutforherweightandmoodaswell.TheGPshowsthepatientascreenwhereshecanseeherpainscorecomparedtootherpeoplelikeherandseesthatifshekeepsusingtheappitlooksasthoughherLBPwillimprove.ThepatienttakesthisasencouragementbutisalsoconfusedabouthowtheGPcanbesureaboutthis.TheGPexplainsthatthisinformationisbasedonotherpatientswhoaresimilartoherintermsofage,sex,andotherimportantcharacteristicssuchasherweight.ThepatientsaysthatshewilltrytodothisandwillcomebackandseetheGPagaininabouttwomonths’time.

6.2 Clinician

AGPhasbeenrecommendinguseoftheSELFBACKtooltoanumberofpatients,somewithnewepisodesofacuteLBPandotherswhohavehadLBPforalongtimeorwhohavehadarecentflare-upintheirpain.TheabovepatienthasbeencomingtoseetheGPregularly(everyonetotwoweeks)fortheirLBPfor6months;onemonthago,theGPsuggestedthatshestarttousetheSELFBACKapp.Whenthepatientcomesintotheconsultingroom,theGPasksherhowsheisandhowisherLBP.Shereportsthatshehasbeenusingtheappbutthatherpainhasnotgotanybetter.TheGPasksthepatientifshecanlookatherSELFBACKprofilewithher.ThepatientprovidestheGPwithapersonalIDcodeandthentheGPenters

Page19of22


thiscodeintothesystemandbringsupthepatient’sprofile.TheGPcanseeonthepainintensityprogressgraphthatherpainhasactuallygonedownfrom7whenshefirststartedusingtheapp,to5justtwodaysago.Showingthistothepatient,allowedtheGPtohighlightthis.Asthispatienthasaphysicallyactivejobbutdoesn’tthinkthatexercisehelpsher,theGPaskedaboutherexerciseandwalkingroutine.TheGPbroughtuptheactivityprogressscreenandseesthatthepatientisnotmakinghertargetnumberofsteps,butshehasincreasedheractivityfromthefirstweek.TheGPshowsheractivityinrelationtootherpeoplelikeher,similarweightandage,andshecanseethatshecouldbemoreactive.TheGPasksherwhysheisnotdoingasmuchandshereiteratesherworrythatitwillcausemorepainandindeedtheGPcanseethiswhentheylooksattheTAMPAscoregraph,thishasnotchangedfromthefirstuseoftheapp.TheydiscusswhythismightbeandtheGPisabletoreassurethepatientandencouragehertopayspecialattentiontotheeducationalcomponentontheapptounderstandmoreaboutwhatcausesLBPandthatphysicalactivityisn’tdamaging.ThepatientleavestheconsultationwiththeGPfeelingpositiveasshecanseethatothersimilarpatientswhohavefollowedtheguidancehavehadanimprovementintheirpain.TheGPsuggeststhatsheleavesitfortwomonthsbeforecomingback,unlessthereissomethingdifferentorchangedaboutherLBP.

Page20of22


7 TheimplementationoftheSELFBACKClinicianDashboardinClinicalPractice

Below,wedescribethemainchallengesandhowexploitationoftheresultsfromtheSELFBACKprojectmayhelptoadvancetheimplementationofcomputerizedsupportandshareddecision-makinginclinicalpractice.

7.1 Patientgenerateddata

Tofacilitatepreciseandwell-informeddecisions,itisimportanttohaveaccesstovalidandrelevantdatafortheconsultingpatient.Someofthesedatamaybecollectedbythepatienthim-/herself,i.e.,patientgenerateddata(PGD).Forconditionswhereself-managementconstitutesacorecomponent,suchasforLBP,itwillbeparticularlyrelevanttohavetime-seriesPGDabouttheself-managementprocesswhenthepatienthasregularfollow-upconsultations.Suchtime-seriesPGDshouldtaketheformofrepeatedachievement(self-management)andoutcome(symptomprogression)measurements,suchasthePGDcapturedbytheSELFBACKsystem.WhenclinicianshaveaccesstoPGDinastructuredsetting,theyreportthreemainbenefitswithdirectrelevanceforshareddecision-making:

1) Improvedinsightintotheconditionofindividualpatients,2) Improvedgeneralandclinicalinformationaboutthepatient,3) Betterinsightintosymptomvariationandhealthbehaviourbetweenconsultations,

enablingrevisionoftreatmentplanstoimproveoutcomesandavoidunnecessaryconsultations.4

Insummary,thisislikelytofacilitatetheshareddecision-makingbetweenthepatientandtheclinician.

7.2 Barriersforimplementation

ThemainbarriersforimplementingPGDinclinicalpracticearecentredaroundthefollowingaspects:

1) Technical/ethicalissues(collectionandstorageofPGD,patientprivacyconcerns),2) TimeconstraintsandusabilityofPGDinclinicalpractice(accesstothePGDduringa

consultation,howtouseandinterpretthePGDdata),and3) Culturalissueswithintheclinicalcommunity(lackofpracticeworkflowsand

protocolsrelatedtocollectionanduseofPGD).1,4,5Tofacilitatetheimplementationofshareddecision-makingandtheuseofPGDineverydayclinicalpractice,atleastfourrequirementsmustbemet:

1) EasyaccesstoPGDthatensurespatientprivacy,2) Easyaccesstoevidence-basedinformationabouttreatmentoptions,3) Guidanceonhowtoweighthebenefitsandrisksofdifferenttreatmentapproaches,

and4) Acceptancewithintheclinicalcommunitytousethecliniciandashboard

Page21of22


5) Encourageclinicianstoengageinco-decisionmaking.Thesedatawillallowcliniciansandpatientstogaininsightsintotheprogressionandimpactofsymptoms.6Thus,althoughsomepromisingresultshavebeenpresented,thereisstillneedforfurtherresearchtounderstandhowaccesstosuchdatacanbeimplementedandutilisedinclinicalpractice.

Apotentiallyimportantinputtotheprocessofshareddecisionmakingbetweenthepatientandclinicianisdatacollectedovertimebywearableactivitytrackingdevices.Suchdatamaybeofparticularrelevanceforfollow-upofpatientswithchronicconditionsanddiseaseswhereself-managementisabasicingredientofdiseasemanagement.Recentstudiesshowthatabout21%ofadultAmericansusetechnology(smartphones,smartwatchetc.)totrackhealthindicators(exercise,routines,sleep,etc.,weight,diet,orexerciseroutinesinsomemanner.4

7.3 Exploitationofthecliniciandashboard

IntheSELFBACKproject,theco-decisionmoduleisdevelopedasashowcaseandwillnotbeimplementedintherandomisedcontrolledtrial.However,thepotentialforimplementingsuchatoolinclinicalpracticeinthefutureispromising.Thebarrierforitsimplementationisfirstandforemostthetimeconstraintsandprivacyissuerelatedtosharingofdata.AGPwilltypicallyhave10minutesavailableperpatient.Fromapatientperspective,theprivacyissueseemstobelessimportantiftheyseeavalueinit.ArecentstudybyPwCshowedthat88%ofpatientsarewillingtosharedatafrom,e.g.,theiractivitytrackerdeviceandsmartphone,ifthiscanimprovetreatmentandhelpotherpatientsinsimilarsituations5.However,thetechnicalsolutionforsuchdatasharingisstillachallenge.

7.4 SummaryandFutureWork

Herewehavedevelopedanin-depthproposalanddemonstrationofthepotentialofaClinicianDashboardtoworkalongsidetheSELFBACKdecisionsupporttoolfortheself-managementofLBP.Wehavecreatedwireframesandprovidedexamplesofhowthedashboardcouldworkinpractice,includingpotentialchallengestoitsimplementation.Basedonourfindings,wewillusethewireframesandreviewthemwithclinicalpractitionersandpatientusergroups.Aftertheirfeedback,wewillcreateademonstratorconnectedtotheSELFBACKbackendinordertodisplaypatient’sdata.Furtheron,necessarydatasecuritymeasureshavetobeimplementedandtested.

4http://www.pewinternet.org/2013/01/28/tracking-for-health/5https://www.pwc.com/il/en/pharmaceuticals/assets/healthcare-unwired.pdf

Page22of22


References

1. ElwynG,LaitnerS,CoulterA,WalkerE,WatsonP,ThomsonR.ImplementingshareddecisionmakingintheNHS.Bmj.2010;341:c5146.

2. GravelK,LegareF,GrahamID.Barriersandfacilitatorstoimplementingshareddecision-makinginclinicalpractice:asystematicreviewofhealthprofessionals'perceptions.Implementationscience:IS.2006;1:16.

3. LegareF,RatteS,StaceyD,etal.Interventionsforimprovingtheadoptionofshareddecisionmakingbyhealthcareprofessionals.TheCochranedatabaseofsystematicreviews.2010(5):Cd006732.

4. CohenDJ,KellerSR,HayesGR,DorrDA,AshJS,SittigDF.Integratingpatient-generatedhealthdataintoclinicalcaresettingsorclinicaldecision-making:lessonslearnedfromprojecthealthdesign.JMIRhumanfactors.2016;3(2):e26.

5. ChiauzziE,RodarteC,DasMahapatraP.Patient-centeredactivitymonitoringintheself-managementofchronichealthconditions.BMCmedicine.2015;13:77.

6. ShammasL,ZentekT,vonHaarenB,SchlesingerS,HeyS,RashidA.Home-basedsystemforphysicalactivitymonitoringinpatientswithmultiplesclerosis(Pilotstudy).Biomedicalengineeringonline.2014;13:10.

7. CoieraE,LauAYS,TsafnatG,SintchenkoV,MagrabiF.Thechangingnatureofclinicaldecisionsupportsystems:afocusonconsumers,genomics,publichealthanddecisionsafety.IMIAyearbookofmedicalinformatics2009.2009;84-95.

8. BernerES.Clinicaldecisionsupportsystems:stateoftheart.Agencyforhealthcareresearchandquality.AHRQpublicationno.09-0069-EF.2009.

Documents

Page 2 of 22 - Selfback › uploads › 1 › 0 › 7 › 1 › 107154065 › d4_3_sp… · Page 5 of 22 D 4.3: Clinician Dashboard Design (SPECW) SELFBACK Dissemination Level: CO