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NUR 353 Group 4 Padlet Presentation: Patient Engagement and Connected Health. GROUP CHARTER:

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NUR 353 Group 4 Padlet Presentation: Patient Engagement and Connected Health. GROUP CHARTER:

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*Kristie Willis: Connected health champion, video link for connected health.
*Derrick Storball: Video link Champion for Connected Health and patient engagement
*Kristen Smithers: Create Padlet account, Patient engagement champion & Peer reviewed article
* Each member of the team will provide a summary of the discussion on Day 7 of the discussion week.

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1) Can you think of any ways that utilizing technology to engage in connected health could be advantageous especially in this time of a global pandemic?

2) Can connected health tools be used in all settings such as ER and other specialties or is it simply a tool for primary care and inpatient nurses? Give examples please.

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Patients have a vested interest in their healthcare

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Patients have a vested interest in their healthcare

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What are some benefits of patient engagement?

-Studies find that some patients who have access to health records online agree with practitioners that they improve safety. Access to online medical records has been linked with an increase in patient medication compliance.

https://www.jmir.org/2019/4/e12779/

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Real world examples of technology & how it improves patient engagement

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Real world examples of technology & how it improves patient engagement

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https://ehrintegration.com/solutions/patient-experience/

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Improving the Patient Experience

Optimizing patient engagement and experience is a top priority as an important part of providing patient-centered, value-based care. The patient experience should be pleasant, hassle-free, and efficient, leaving your patients satisfied with the quality of their time at your practice. Plenty of evidence demonstrates a positive association between a good patient experience and desired results such as adherence to medical advice, better clinical outcomes, increased safety practices, and improved client engagement.

The patient experience includes all of the interactions and administrative processes your patients have with your practice, from front-office check-in to verifying insurance eligibility, to medical billing and more. By looking at the different experiences and interactions that define your patient experience, you can better assess if your patients are receiving appropriate care that is respectful of and responsive to individual preferences, needs, and values. To gauge patient experience, you need to find out directly from your patients if something that should happen in the clinical environment actually occurred, as well as how often it occurred.

EHR Integration Services envisions a "Human Approach to Healthcare" and our patient experience solutions are an integral part of that vision. Our solutions supply healthcare practitioners with the applications and insights that strengthen their relationship with patients. That improves the overall quality of your care while improving patient satisfaction with their clinical experience. We work with several of our technology partners to provide healthcare practitioners with the solutions they need to optimize patient experience.

Transforming Patient Intake and Check-In

Our Patient Check-in suite of connected technologies is transforming patient intake and check-in processes for practices, hospitals, and health systems. This innovative approach to patient check-in puts the patient back in control of their care experience by replacing outdated, paper-based administration with a connected HIT suite that addresses all aspects of patient intake. Patients can easily check in to appointments, remit payments, and verify their insurance eligibility. EHRis patient check-in solutions are helping people take a proactive approach to manage their care while providing practices with improved operational efficiency, reduced overhead, and significantly higher payment collections at the point of service.

Alert office staff that they have arrived

Verify or change their address, insurance information, health status, or update other demographics as well as driver's license or prescriptions

Notify office staff of their communication preferences

Payments can be processed directly from the kiosk, increasing convenience for your patients and revenue for your practice.

Reduce staff workload with patient self-registration

Improve forms management

Reduce patient registration errors

Double point-of-service collections

Reduce paper work & paper costs

Reduce wait time and increase patient satisfaction

Keep Your Patients Engaged with A Patient Portal

EHRis is setting new standards for patient engagement. With an increasing demand for better customer service and access to secure personal health information (PHI), our patient engagement solutions are mobile-ready and available from any location. Our EHR-agnostic portals are able to connect to any EHR, giving patients an unprecedented view of their PHI data including lab results, demographics, immunizations, and health history. In addition, our patient portal lets you communicate with patients in a variety of ways with direct secure messaging, SMS, email and push notification so patients can always connect with their providers and be actively engaged in their healthcare. We also offer patient self-scheduling, patient-provider messaging, bill pay and advanced reporting to offer a comprehensive solution for your practice.

Connects to Multiple EHR's Simultaneously

User-friendly and Mobile-ready

Improves Interoperability

EHR-agnostic

Comprehensive Reporting

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Patient Experience - Solutions | EHR Integration Services

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Optimizing patient engagement and experience is a top priority as an important part of providing patient-centered, value-based care. The patient experience should be pleasant, hassle-free, and efficient, leaving your patients satisfied with the quality of their time at your practice.

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Patient Engagement explained in a simple video

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Patient Engagement explained in a simple video

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https://www.youtube.com/watch?v=bTDkCPc7zeM

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fun games related to Patient Engagement and Connected Health. - - Video Search Results

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The search engine that helps you find exactly what you're looking for. Find the most relevant information, video, images, and answers from all across the Web.

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Healthcare APIs: Achieving interoperability & improving patient engagement

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Phunware Healthcare Solution: Digital Front Door

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"More and more people, in a trend known as consumer empowerment, patient engagement, and connected health, are interested in partnering with healthcare providers to take control of their health" (McGonigle & Mastrian, 2018). 

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"More and more people, in a trend known as consumer empowerment, patient engagement, and connected health, are interested in partnering with healthcare providers to take control of their health" (McGonigle & Mastrian, 2018). 

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https://aprescriptionforme.wordpress.com/2017/07/18/more-power-to-you-m-e-patients-found-to-be-the-least-empowered/

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https://www.wegohealth.com/2018/10/30/patient-empowerment/

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Patient empowerment. There's no single, agreed-upon definition of what it is or how to get to it.

But, patient empowerment is generally seen as leading to collaborative, coordinated care. It supports an approach to care that honors the patient's preferences, values, cultural traditions, and socioeconomic conditions. All of these characteristics are cornerstones of patient-centered healthcare, which is seen as fostering high-quality care for all.

What is patient empowerment?

Patient empowerment requires the active participation of patients, providers, and policymakers -

How you define patient empowerment depends on who you ask. It's been described as a process, a set of actions, a skill, and a value.

A process

The World Health Organization (WHO) defines patient empowerment as a . Specifically, "a process through which people gain greater control over decisions and actions affecting their health."

Both the individual and the community play a part in this process, which the WHO says has four requirements:

The patient understands their role

The patient acquires enough knowledge to be able to engage with their healthcare provider

The patient has the skills needed to manage their health

The healthcare environment and community facilitate the patient's health-related activities and efforts

When these requirements are met, a process can take place "in which patients...are given the knowledge and skills by their healthcare provider to perform a task in an environment that recognizes community and cultural differences and encourages patient participation."

This definition comes across as paternalistic. It keeps the healthcare provider as the driver of the process, "giving" knowledge and skills to the patient who performs the health-related task.

A set of actions

The Center for Advancing Health (CFAH), describes patient empowerment as "the actions we (i.e., patients) take to support our health and to benefit from health care."

In its Engagement Behavior Framework, CFAH identified 42 actions that patients and/or their caregivers must take to maximize the benefit received from their available healthcare.

Organized around ten themes, these actions include:

Finding healthcare providers who satisfy the patient's personal criteria

Finding providers who are accepting new patients and the patient's health insurance

Preparing questions in advance of doctor appointments

Gathering additional expert opinions before starting a new course of treatment for a serious illness

Changing behavior to maximize health and wellbeing

Discussing end-of-life wishes and values with healthcare providers, caregivers, and family members

Putting advance directives and a power of attorney in place

Here, the patient is the driving force behind the actions taken. The patient's whole life, not just instances of illness or health concerns, is considered or managed in this empowerment framework.

A skill

Emil Chiauzzi, PhD, the principal scientist at Patients Like Me, characterizes patient empowerment as "a finely-tuned skill providers and patients develop together."

The skill is made up of:

Problem solving

Communications

Ability to seek out resources

Understanding of the disease

Understanding of the associated treatments

This definition of patient empowerment suggests an active partnership between patients and providers. It calls on providers to make educational resources available and to allot the time needed to work with patients in order to meet their needs. It also calls on patients to become empowered through their own learning and understanding of their health and disease.

A value

The Patient Empowerment Network (PEN) articulates a collaborative approach to patient empowerment that focuses on "the value of having patients assert greater control over their health and healthcare."

PEN identifies seven essential components for patient empowerment:

Information

Health literacy

Digital literacy

Self-efficacy

Mutual respect

Shared decision-making

A facilitating environment

PEN points to the rise of technology and apps as being largely responsible for changing the dynamic between patients and providers. These changes are key to the growth in patient empowerment.

Empowerment is not the same as engagement

With engagement, patients are no longer the target of actions taken by others -

The goal of patient empowerment is to have patients make informed decisions and take actions that support their overall health.

Unlike patient engagement, which is primarily aimed at getting patients to be more adherent and compliant, patient empowerment aims to create the conditions needed to help patients follow through on better health decisions they themselves make.

The notion of empowerment comes from the patient being the primary decision-maker, based on their own understanding of their health, their aspirations, and their healthcare provider's expertise. What it means to be "better" is relative to the patient's own values and desires for their overall health and quality of life.

Patient empowerment supports patient-centered care

Patients who are empowered tend to seek out more than one source of information about their condition. Patients and providers engage in more shared decision-making. And, patients collaborate with their provider to pursue care that aligns with their values, culture, preferences, and socioeconomic conditions.

No longer is the patient the passive recipient of the provider's expertise and instructions. Nor is the provider the authority making care decisions regardless of the patient's values and circumstances.

Together, the conditions that make up patient empowerment facilitate the patient-provider collaboration that is at the core of patient-centered care and will lead to higher quality care for all.

Who is the empowered patient?

Empowered patients tend to be assertive, making healthcare decisions for themselves -

Patients Like Me (PLM) surveyed members of their patient research network in an effort to characterize empowered patients.

In terms of behavior, PLM found that empowered patients ask more questions. They seek more detailed explanations about their conditions and related issues. To feel comfortable asking questions of healthcare providers, patients need to feel confident in their level of education and understanding of health and medicine. They also must be confident that their provider will remain available and engaged for as long as it takes to build patient understanding.

PLM also found that not all patient groups across all health conditions demonstrated the same level of empowerment. Patients with conditions that are more easily diagnosed and more visible (like Parkinson's and Multiple Sclerosis) self-reported a higher level of empowerment than patients with conditions that are more difficult to diagnose or less visible (like chronic fatigue syndrome and fibromyalgia).

One possible explanation for this disparity is that the stigma attached to less visible conditions undermines patients feeling empowered. Patients with stigmatized conditions often find that providers and caregivers doubt or, in some cases, dismiss their reported symptoms and health experiences.

In characterizing the demographics of empowered patients, PLM reported that patients who self-identified as empowered tended to be more educated, with a higher level of insurance, and male. To some degree these results are not surprising since educational achievement, insurance coverage, and male gender are perceived to be social advantages.

How can we encourage more patients to become empowered?

Addressing social determinants of health can provide significant leverage to improve health outcomes -

For the benefits of patient empowerment to be fully realized, empowerment needs to reach beyond the privileged few and those with the most visible illnesses. Engagement tactics alone (like enabling knowledge and encouraging shared decision-making) won't be effective in spreading empowerment because they don't reach all patients.

The formula for widespread patient empowerment, and the benefits of patient-centric care that come along with it, lie in addressing social determinants of health. By addressing social determinants, all patients have the opportunity to gain the literacy and skills needed to actively manage their health and make better-informed decisions.

There are nearly thirty widely-accepted social determinants of health. Out of this complex web of factors, three have been identified as creating the most favorable conditions for expanding patient empowerment.

Surprisingly, these three factors go beyond the clinical setting. They are:

Making health insurance accessible to all

Addressing language barriers in care

Addressing basic needs (i.e., food, housing, and financial insecurity)

Insurance accessibility

Having health insurance has a direct effect on access to healthcare. Those without insurance are substantially less likely to access healthcare recently or regularly. This often means that those without insurance don't seek care until they are experiencing a health crisis, making their treatment more complex and expensive.

Language and communication barriers

Language barriers undermine communication between patients and providers with serious consequences. Patients with limited English proficiency are twice as likely to experience adverse medical consequences as English-speakers.

English proficiency is not the only barrier that must be addressed. People with hearing impairments or deafness also need interpreters. And disparities between patients' and providers' level of health literacy can also get in the way of understanding and communication needed to get to better-informed health decisions.

Addressing basic needs

It's widely-accepted that when people live in poverty or in under-resourced communities, their health suffers, and life expectancy is shortened. Community-wide action is needed to provide people with their basic needs for food, housing, and security.

Additionally, to ensure that basic needs are met across social and economic lines, a "health is in all policies" approach needs to be adopted. Governmental actions and decisions made outside of "purely health" policy will often have an effect on health. Actions and decisions made in one neighborhood can affect others. These effects need to be recognized and consciously managed to build healthy communities for everyone - not just some.

Patient empowerment doesn't happen in a vacuum

Much is made of the concept of patient empowerment. Empowerment is held up as the key to better healthcare decisions and better health. And while the decision-making power rests with the patient, that patient cannot make those decisions in a vacuum. A host of skills, actions, processes, and values are needed to inform patients and their decisions for true empowerment to be realized.
In my next article, I'll discuss how the patient is being transformed into a health consumer as one model for patient empowerment.

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Patient Empowerment: The Path to Better-Informed Health Decisions

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Patient empowerment. There's no single, agreed-upon definition of what it is or how to get to it. But, patient empowerment is generally seen as leading to collaborative, coordinated care. It supports an approach to care that honors the patient's preferences, values, cultural traditions, and socioeconomic conditions.

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60 Seconds for Safety: Patient Engagement

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Patient involvement with home-based exercise programs:  Can connected health interventions influence adherence?

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Viewpoint

¹ Beacon Hospital, Dublin, Ireland

² Insight Centre for Data Analytics, University College Dublin, Dublin, Ireland

³ School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland

Corresponding Author

Corresponding Author:

Rob Argent, BSc (Hons)

Beacon Hospital

University College Dublin Beacon Academy

Sandyford

Dublin, D18

Ireland

Phone: 353 01 540 4646

Email: rob.argent@insight-centre.org

ABSTRACT

Adherence to home exercise in rehabilitation is a significant problem, with estimates of nonadherence as high as 50%, potentially having a detrimental effect on clinical outcomes. In this viewpoint, we discuss the many reasons why patients may not adhere to a prescribed exercise program and explore how connected health technologies have the ability to offer numerous interventions to enhance adherence; however, it is hard to judge the efficacy of these interventions without a robust measurement tool. We highlight how well-designed connected health technologies, such as the use of mobile devices, including mobile phones and tablets, as well as inertial measurement units, provide us with the opportunity to better support the patient and clinician, with a data-driven approach that incorporates features designed to increase adherence to exercise such as coaching, self-monitoring and education, as well as remotely monitor adherence rates more objectively.

JMIR Mhealth Uhealth 2018;6(3):e47

doi:10.2196/mhealth.8518

Citation

Please cite as:

Loading authors...

KEYWORDS

Introduction

The success of certain medical interventions depends largely on patient adherence to advice and prescribed rehabilitation regimes. After injury or surgery, many patients are given specific exercises to do unsupervised at home to aid their recovery, for example after knee replacement. These exercises are specifically targeted at certain muscle groups or joints, rather than global physical activity, for example a straight leg raise for quadriceps strength or a heel slide for knee range of movement. Evidence suggests that noncompliance to these home exercises in musculoskeletal cohorts can be between 30% and 50%, making it a significant issue that places additional burden on patients and health care providers, and may be partially to blame for poor clinical outcomes [,]. Clinicians who fail to consider patient adherence in rehabilitation programs may unnecessarily alter their treatment approach, face persistent patient complaints; or refer patients for alternative opinion, thereby contributing to possible unnecessary surgical intervention and additional health care costs []. Adherence is currently defined by the World Health Organization (WHO) as "the extent to which a person's behaviour...corresponds with agreed recommendations from a health care provider" []. The majority of research into adherence relates to medication, and this definition has been developed to encompass a multitude of health-related behaviors [], however, it does not yet include exercise prescription. In this viewpoint, we aim to comment on the current evidence in patient adherence to prescribed home exercise programs, the factors affecting these adherence rates, and then discuss design opportunities that connected health interventions provide to improve adherence rates.

The term connected health describes the use of a variety of technologies to inform and aid health care delivery in a data-driven manner with the individual at the center. It covers a broad domain, including digital, mobile health and telehealth and ensures all stakeholders are connected with data that is accurate and timely []. Mobile technology, including smartphones and tablets can support connected health solutions by providing access to a number of features within the device, including inertial measurement units (IMUs), cloud computing, and back-end development including machine-learning classification []. Equally, various methods such as telerehabilitation using videoconferencing [], or motion capture using camera systems [] have been employed with the aim to better support patients in their rehabilitation and improve their adherence. But what are the design features that can be harnessed in new connected health solutions that will impact adherence to exercise?

Adherence to Exercise Programs

An Operational Definition of Adherence in Exercise Science

Although medical adherence has been defined by the WHO, it is arguable that there is more than one factor to consider when specifically defining exercise adherence. To form a definition, the authors of this paper have considered on a macro level, the requirements needed to demonstrate strong adherence. Clinicians first need to know whether the patient is exercising, then whether they are exercising to the required amount of repetitions and sets, and finally whether they are performing the correct technique with relation to load, velocity, and alignment. The following operational definition has been built specifically relating to exercise, adapted from the WHO definition, and defines exercise adherence as "the extent to which an individual corresponds with the quantity and quality of exercise, as prescribed by their healthcare professional." Those who perform their exercises to the required repetitions may not be deemed adherent should their technique be erroneous or incorrect, as these individuals will not be gaining maximum benefit from their exercise program.

The Effect of Adherence on Outcome

In an exercise rehabilitation context among the musculoskeletal population, strong adherence enhances the effectiveness of the intervention and is suggested to reduce persistent, disabling complaints []. Patients who fail to adhere to the prescribed exercise program may extend the duration of their treatment, negatively impact on the therapeutic relationship, and make treatment less effective []. It can also impact health care providers with increased waiting times and poor efficiency [], while poor adherence rates may also potentially have a role to play in nonsignificant outcomes of research papers []. A number of studies have also linked strong exercise adherence to improved treatment outcome in patients experiencing neck and back pain and osteoarthritis symptoms [-].

Rates of Adherence

Measuring Adherence

Factors Affecting Adherence

Overview

Self-Efficacy

Self-efficacy has been strongly linked as a psychological factor affecting treatment adherence. It is a term used to describe an individual's belief in their own capability to achieve a task that will produce a targeted result. It is situation-specific and depends on the activity, but it is considered that a person has a general level of self-efficacy across tasks []. Four strands of efficacy information are proposed within the concept; mastery experiences based on past and current successful performance, social observation learning from those around the individual, persuasive information particularly from influential people in the individual's life, and emotional states considering the mood the individual is in []. Self-efficacy has been closely linked with a positive association of adherence in orthopedic and musculoskeletal cohorts [,,]. It is worth noting however, that one study found that self-efficacy did not predict adherence in the home or clinic setting, although this was assessed in a sports rehabilitation context, and therefore may not be generalized to other cohorts []. When designing connected health solutions, there is an opportunity to use interventions to improve self-efficacy within the technology design. Methods such as machine learning with biofeedback, interactive education using videos and weblinks, and self-monitoring similar to that used in commercially available fitness trackers, have the potential to improve the self-efficacy and ultimately the adherence of users.

Threat and Beliefs

The beliefs a patient holds regarding their condition are also said to be a direct factor affecting adherence, and the decisions made by patients are based on their own beliefs, personal experiences, and the information they receive []. This study noted that those who did not perceive their injury to be serious demonstrated lower levels of adherence, and in fact, the authors suggested that enhancing participants' level of threat to further injury or disability would improve adherence, although this is a questionable technique in the wider context of patient management. Indeed, others have stated that providing too much information to patients and overloading them will also negatively affect adherence, as patients can become confused []. Enhanced threat can also have other negative implications, such as hemophiliac patients who may have had a threat of increased bleeding and arthropathy with physical activity [], and therefore treatment should be about correcting falsely construed beliefs and tailoring individual care, rather than solely modifying the threat appraisal for all patients. This individualized care is an important consideration in the design of connected health solutions, as the end user needs to be considered and technology should be used to augment the clinician's management, rather than to replace in a one size fits all approach that may incorrectly adjust a user's beliefs. Symptoms also need to be perceived to have a sufficient effect on quality of life to encourage adherence [], with another viewpoint that the beliefs a patient holds places them in a similar category as consumers, who want to take their own decisions when confronted with a particular condition [].

Locus of Control

Pain

Physical Activity

Psychological Symptoms

Social Support

The social support network of the patient has also been suggested as a possible factor in adherence [,]. This network can be friends and family members, as well as support from the therapist. In the sporting population, significant findings were made that both social support as task appreciation, and emotional support from friends and family predict adherence in both the clinic and home setting []. Further exploratory work in the sporting population made suggestions that those who made use of social support displayed greater adherence and recommended that in this setting, the coach and wider support network are involved in the rehabilitation pathway to offer support and motivation []. Connected health solutions have the potential to offer social support through online forums or networks where users are able to interact with others in a similar situation, wherever they may be. It is not impossible to foresee a social network built into many mobile health technologies to enhance patient experience and improve adherence. A recently published systematic review found relatively strong evidence that social support can predict adherence, but as discussed earlier, highlighted the challenge of measurement of adherence as a significant limitation across the field [].

Perceived Barriers

Design Considerations for Connected Health Solutions

Overview

When designing future connected health solutions, it is important to have an understanding of the range of possible cognitive, behavioral, and practical barriers that can have an effect on a patient's willingness to adhere to their program []. The use of mobile devices connected with a form of sensing platform (camera or IMU) in home-based exercise rehabilitation have the potential to provide the clinician with a greater amount of actionable data, which will assist in the management of each case and shift to a more proactive approach to health care. By understanding the factors discussed previously, it is possible to build features and interventions in to new solutions with the aim of enhancing patient adherence and ultimately, clinical outcome.

Coaching

By incorporating regularly combined strategies of supervision, feedback, and reinforcement as a design consideration, it is possible to offer the greater coaching input that a patient receives in clinic with their health care professional but in the convenience of their home environment. When physiotherapists provide positive feedback, and monitor both performance of exercises and the progression of symptoms, adherence rates have been found to be higher []. The design of connected health interventions can then offer supervision in the form of remote monitoring via online cloud-based portals. This coaching system can be augmented with remote communication using platforms such as videocalling, instant messaging, or email to offer further coaching components. Telerehabilitation has been extensively researched by a Canadian group who in one study of postoperative knee replacement patients found telerehabilitation in the form of videoconferencing to be as effective as usual care and had the potential to increase access to services [].

Task appreciation, when patients are complimented for their achievements, particularly for adherence [], is particularly applicable in the gamification of health interventions to further compliment a user's achievements. Whether this is via rankings, rewards, in-exercise games, or simply augmenting the experience with an avatar type feedback, the user can enjoy a more immersive experience within a connected health technology, potentially impacting on their adherence.

Goal Setting

Self-Monitoring

Education

Education is also an intervention to improve adherence; it is multifactorial and can affect perceived barriers and the patients' beliefs/perceived threats that are discussed above. Studies using solely education are few and far between, but in a systematic review, no statistically significant findings were made on 2 fair quality studies, but the provision of written information in supplement to verbal instruction did improve adherence compared with verbal instruction alone []. A recent symposium piece also concluded that patients rarely need just more education, they need assistance with behavior change in an integrated program [], perhaps suggesting that clinicians should be more aware of the psychological theories discussed previously. Whether Web-, tablet-, or mobile phone-based, connected health solutions can easily offer educational material in a variety of formats, including more interactive methods such as videos that would not have been available in the past to patients.

Conclusions

Adherence to home exercises in rehabilitation is a significant problem, and the reasons for this are multifactorial, covering both psychological and situational factors that vary between each individual, and that need to be considered by clinicians in the design of personalized exercise programs. Techniques discussed in this paper can be built into connected health solutions with the aim to improve self-efficacy and ensure the patient feels better supported in their rehabilitation; this may have an effect on adherence rates and will provide clinicians with more meaningful data to base their clinical decision on. Furthermore, published research needs to investigate the impact of these solutions on adherence rates, as this is sparse at present, yet this is understandable given the difficulties in measuring adherence discussed within the paper.

Connected health technology has the potential to make an impact in the way we manage health and can provide a platform for a far more proactive method of management utilizing numerous interventions to further improve adherence, and ultimately rehabilitation outcomes for patients. There is an emerging market in the use of sensing systems to support patients in their rehabilitation, particularly around adherence to home exercise, although the published research is still in its infancy. These systems have the ability to include many of the design features discussed in this viewpoint within the developed system and have the ability to utilize ubiquitous and cost-effective hardware in the form of mobile phones and tablets. It may then also be possible for these systems to provide a more objective method of measuring adherence across clinical populations.

Acknowledgments

This project is part of the Connected Health Early Stage Researcher Support System Initial Training Network and has received funding from the European Union's Horizon 2020 research and innovation program under the Marie Sklodowska-Curie grant agreement no 676201.

Conflicts of Interest

None declared.

‎
Abbreviations

Edited by C Dias; submitted 20.07.17; peer-reviewed by M Khazaeepool, J Rawstorn, E O'Leary; comments to author 03.10.17; revised version received 27.11.17; accepted 29.11.17; published 01.03.18

©Rob Argent, Ailish Daly, Brian Caulfield. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 01.03.2018.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR mhealth and uhealth, is properly cited. The complete bibliographic information, a link to the original publication on http://mhealth.jmir.org/, as well as this copyright and license information must be included.

ABSTRACT

Adherence to home exercise in rehabilitation is a significant problem, with estimates of nonadherence as high as 50%, potentially having a detrimental effect on clinical outcomes. In this viewpoint, we discuss the many reasons why patients may not adhere to a prescribed exercise program and explore how connected health technologies have the ability to offer numerous interventions to enhance adherence; however, it is hard to judge the efficacy of these interventions without a robust measurement tool. We highlight how well-designed connected health technologies, such as the use of mobile devices, including mobile phones and tablets, as well as inertial measurement units, provide us with the opportunity to better support the patient and clinician, with a data-driven approach that incorporates features designed to increase adherence to exercise such as coaching, self-monitoring and education, as well as remotely monitor adherence rates more objectively.

JMIR Mhealth Uhealth 2018;6(3):e47

doi:10.2196/mhealth.8518

Citation

Please cite as:

Loading authors...

KEYWORDS

Introduction

The success of certain medical interventions depends largely on patient adherence to advice and prescribed rehabilitation regimes. After injury or surgery, many patients are given specific exercises to do unsupervised at home to aid their recovery, for example after knee replacement. These exercises are specifically targeted at certain muscle groups or joints, rather than global physical activity, for example a straight leg raise for quadriceps strength or a heel slide for knee range of movement. Evidence suggests that noncompliance to these home exercises in musculoskeletal cohorts can be between 30% and 50%, making it a significant issue that places additional burden on patients and health care providers, and may be partially to blame for poor clinical outcomes [,]. Clinicians who fail to consider patient adherence in rehabilitation programs may unnecessarily alter their treatment approach, face persistent patient complaints; or refer patients for alternative opinion, thereby contributing to possible unnecessary surgical intervention and additional health care costs []. Adherence is currently defined by the World Health Organization (WHO) as "the extent to which a person's behaviour...corresponds with agreed recommendations from a health care provider" []. The majority of research into adherence relates to medication, and this definition has been developed to encompass a multitude of health-related behaviors [], however, it does not yet include exercise prescription. In this viewpoint, we aim to comment on the current evidence in patient adherence to prescribed home exercise programs, the factors affecting these adherence rates, and then discuss design opportunities that connected health interventions provide to improve adherence rates.

The term connected health describes the use of a variety of technologies to inform and aid health care delivery in a data-driven manner with the individual at the center. It covers a broad domain, including digital, mobile health and telehealth and ensures all stakeholders are connected with data that is accurate and timely []. Mobile technology, including smartphones and tablets can support connected health solutions by providing access to a number of features within the device, including inertial measurement units (IMUs), cloud computing, and back-end development including machine-learning classification []. Equally, various methods such as telerehabilitation using videoconferencing [], or motion capture using camera systems [] have been employed with the aim to better support patients in their rehabilitation and improve their adherence. But what are the design features that can be harnessed in new connected health solutions that will impact adherence to exercise?

Adherence to Exercise Programs

An Operational Definition of Adherence in Exercise Science

Although medical adherence has been defined by the WHO, it is arguable that there is more than one factor to consider when specifically defining exercise adherence. To form a definition, the authors of this paper have considered on a macro level, the requirements needed to demonstrate strong adherence. Clinicians first need to know whether the patient is exercising, then whether they are exercising to the required amount of repetitions and sets, and finally whether they are performing the correct technique with relation to load, velocity, and alignment. The following operational definition has been built specifically relating to exercise, adapted from the WHO definition, and defines exercise adherence as "the extent to which an individual corresponds with the quantity and quality of exercise, as prescribed by their healthcare professional." Those who perform their exercises to the required repetitions may not be deemed adherent should their technique be erroneous or incorrect, as these individuals will not be gaining maximum benefit from their exercise program.

The Effect of Adherence on Outcome

In an exercise rehabilitation context among the musculoskeletal population, strong adherence enhances the effectiveness of the intervention and is suggested to reduce persistent, disabling complaints []. Patients who fail to adhere to the prescribed exercise program may extend the duration of their treatment, negatively impact on the therapeutic relationship, and make treatment less effective []. It can also impact health care providers with increased waiting times and poor efficiency [], while poor adherence rates may also potentially have a role to play in nonsignificant outcomes of research papers []. A number of studies have also linked strong exercise adherence to improved treatment outcome in patients experiencing neck and back pain and osteoarthritis symptoms [-].

Rates of Adherence

Measuring Adherence

Factors Affecting Adherence

Overview

Self-Efficacy

Self-efficacy has been strongly linked as a psychological factor affecting treatment adherence. It is a term used to describe an individual's belief in their own capability to achieve a task that will produce a targeted result. It is situation-specific and depends on the activity, but it is considered that a person has a general level of self-efficacy across tasks []. Four strands of efficacy information are proposed within the concept; mastery experiences based on past and current successful performance, social observation learning from those around the individual, persuasive information particularly from influential people in the individual's life, and emotional states considering the mood the individual is in []. Self-efficacy has been closely linked with a positive association of adherence in orthopedic and musculoskeletal cohorts [,,]. It is worth noting however, that one study found that self-efficacy did not predict adherence in the home or clinic setting, although this was assessed in a sports rehabilitation context, and therefore may not be generalized to other cohorts []. When designing connected health solutions, there is an opportunity to use interventions to improve self-efficacy within the technology design. Methods such as machine learning with biofeedback, interactive education using videos and weblinks, and self-monitoring similar to that used in commercially available fitness trackers, have the potential to improve the self-efficacy and ultimately the adherence of users.

Threat and Beliefs

The beliefs a patient holds regarding their condition are also said to be a direct factor affecting adherence, and the decisions made by patients are based on their own beliefs, personal experiences, and the information they receive []. This study noted that those who did not perceive their injury to be serious demonstrated lower levels of adherence, and in fact, the authors suggested that enhancing participants' level of threat to further injury or disability would improve adherence, although this is a questionable technique in the wider context of patient management. Indeed, others have stated that providing too much information to patients and overloading them will also negatively affect adherence, as patients can become confused []. Enhanced threat can also have other negative implications, such as hemophiliac patients who may have had a threat of increased bleeding and arthropathy with physical activity [], and therefore treatment should be about correcting falsely construed beliefs and tailoring individual care, rather than solely modifying the threat appraisal for all patients. This individualized care is an important consideration in the design of connected health solutions, as the end user needs to be considered and technology should be used to augment the clinician's management, rather than to replace in a one size fits all approach that may incorrectly adjust a user's beliefs. Symptoms also need to be perceived to have a sufficient effect on quality of life to encourage adherence [], with another viewpoint that the beliefs a patient holds places them in a similar category as consumers, who want to take their own decisions when confronted with a particular condition [].

Locus of Control

Pain

Physical Activity

Psychological Symptoms

Social Support

The social support network of the patient has also been suggested as a possible factor in adherence [,]. This network can be friends and family members, as well as support from the therapist. In the sporting population, significant findings were made that both social support as task appreciation, and emotional support from friends and family predict adherence in both the clinic and home setting []. Further exploratory work in the sporting population made suggestions that those who made use of social support displayed greater adherence and recommended that in this setting, the coach and wider support network are involved in the rehabilitation pathway to offer support and motivation []. Connected health solutions have the potential to offer social support through online forums or networks where users are able to interact with others in a similar situation, wherever they may be. It is not impossible to foresee a social network built into many mobile health technologies to enhance patient experience and improve adherence. A recently published systematic review found relatively strong evidence that social support can predict adherence, but as discussed earlier, highlighted the challenge of measurement of adherence as a significant limitation across the field [].

Perceived Barriers

Design Considerations for Connected Health Solutions

Overview

When designing future connected health solutions, it is important to have an understanding of the range of possible cognitive, behavioral, and practical barriers that can have an effect on a patient's willingness to adhere to their program []. The use of mobile devices connected with a form of sensing platform (camera or IMU) in home-based exercise rehabilitation have the potential to provide the clinician with a greater amount of actionable data, which will assist in the management of each case and shift to a more proactive approach to health care. By understanding the factors discussed previously, it is possible to build features and interventions in to new solutions with the aim of enhancing patient adherence and ultimately, clinical outcome.

Coaching

By incorporating regularly combined strategies of supervision, feedback, and reinforcement as a design consideration, it is possible to offer the greater coaching input that a patient receives in clinic with their health care professional but in the convenience of their home environment. When physiotherapists provide positive feedback, and monitor both performance of exercises and the progression of symptoms, adherence rates have been found to be higher []. The design of connected health interventions can then offer supervision in the form of remote monitoring via online cloud-based portals. This coaching system can be augmented with remote communication using platforms such as videocalling, instant messaging, or email to offer further coaching components. Telerehabilitation has been extensively researched by a Canadian group who in one study of postoperative knee replacement patients found telerehabilitation in the form of videoconferencing to be as effective as usual care and had the potential to increase access to services [].

Task appreciation, when patients are complimented for their achievements, particularly for adherence [], is particularly applicable in the gamification of health interventions to further compliment a user's achievements. Whether this is via rankings, rewards, in-exercise games, or simply augmenting the experience with an avatar type feedback, the user can enjoy a more immersive experience within a connected health technology, potentially impacting on their adherence.

Goal Setting

Self-Monitoring

Education

Education is also an intervention to improve adherence; it is multifactorial and can affect perceived barriers and the patients' beliefs/perceived threats that are discussed above. Studies using solely education are few and far between, but in a systematic review, no statistically significant findings were made on 2 fair quality studies, but the provision of written information in supplement to verbal instruction did improve adherence compared with verbal instruction alone []. A recent symposium piece also concluded that patients rarely need just more education, they need assistance with behavior change in an integrated program [], perhaps suggesting that clinicians should be more aware of the psychological theories discussed previously. Whether Web-, tablet-, or mobile phone-based, connected health solutions can easily offer educational material in a variety of formats, including more interactive methods such as videos that would not have been available in the past to patients.

Conclusions

Adherence to home exercises in rehabilitation is a significant problem, and the reasons for this are multifactorial, covering both psychological and situational factors that vary between each individual, and that need to be considered by clinicians in the design of personalized exercise programs. Techniques discussed in this paper can be built into connected health solutions with the aim to improve self-efficacy and ensure the patient feels better supported in their rehabilitation; this may have an effect on adherence rates and will provide clinicians with more meaningful data to base their clinical decision on. Furthermore, published research needs to investigate the impact of these solutions on adherence rates, as this is sparse at present, yet this is understandable given the difficulties in measuring adherence discussed within the paper.

Connected health technology has the potential to make an impact in the way we manage health and can provide a platform for a far more proactive method of management utilizing numerous interventions to further improve adherence, and ultimately rehabilitation outcomes for patients. There is an emerging market in the use of sensing systems to support patients in their rehabilitation, particularly around adherence to home exercise, although the published research is still in its infancy. These systems have the ability to include many of the design features discussed in this viewpoint within the developed system and have the ability to utilize ubiquitous and cost-effective hardware in the form of mobile phones and tablets. It may then also be possible for these systems to provide a more objective method of measuring adherence across clinical populations.

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Patient Involvement With Home-Based Exercise Programs: Can Connected Health Interventions Influence Adherence?

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Viewpoint 1 Beacon Hospital, Dublin, Ireland 2 Insight Centre for Data Analytics, University College Dublin, Dublin, Ireland 3 School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland Corresponding Author Rob Argent, BSc (Hons) Beacon Hospital University College Dublin Beacon Academy Sandyford Dublin, D18 Ireland Phone: 353 01 540 4646 Email: rob.argent@insight-centre.org Adherence to home exercise in rehabilitation is a significant problem, with estimates of nonadherence as high as 50%, potentially having a detrimental effect on clinical outcomes.

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