With significant declines in cardiovascular disease (CVD) mortality, attention has shifted to patient management. Programs designed to manage CVD require the involvement of health professionals for comanagement and patients' self-management. However, these programs are commonly limited to large urban centers, resulting in limited access for rural patients. The use of telehealth potentially overcomes geographical barriers and can improve access to care for patients. The current research explores how an Internet-based platform might facilitate collaboration among healthcare providers comanaging patients and enhance behavioural change in patients. Forty-eight participants were interviewed including: (a) patients (
In recent decades, cardiovascular disease (CVD) mortality has decreased substantially in developed countries. This is a result of improved prevention and acute care. As a result of these developments and an aging population, the number of “CVD survivors” (those living with CVD) has increased. Many of these patients’ disease is atherosclerotic in nature for which secondary prevention or cardiac rehabilitation programs are indicated. Effective secondary prevention of CVD is targeted to improve patient quality of life and reduce downstream morbidities. Programs designed to manage this complex chronic disease require the involvement and collaboration of physicians, nurses, allied health professionals, and multiple health services for comanagement, while also requiring knowledge uptake by patients for self-management [
The use of telehealth, defined as the use of advanced telecommunication technologies to exchange health information and health care service, has the potential to resolve these geographical inequities by providing care to patients who would otherwise not be able to receive it due to geographical barriers. Different modalities of ICTs exist for the use of telehealth and include the telephone, the Internet, and telehome monitoring. Studies using the telephone and telehome monitoring have highlighted the potential benefits of ICT use for chronic diseases. For example, the DIAL study reported a 29% reduction in hospital admissions for heart failure following a one-year telephone intervention aimed at supporting patient self-management and monitoring patient symptoms [
The benefits of using the Internet are far less clear. While the Internet has the benefits of being readily accessible, requiring limited resources, able to facilitate data and communication exchange, and is scalable to larger patient groups compared to telehome monitoring devices, comparatively fewer studies have studied this modality. The few studies that have, have been focused primarily on patient acceptance and feasibility, and targeted diseases other than CVD [
Our group has undertaken a number of telehealth initiatives focusing on using an Internet-based chronic disease management platform to deliver patient-focused CVD secondary prevention programs [
The study received IRB approval from UBC and the health authorities involved.
This study took place in three areas within British Columbia, including: Vancouver, the largest city (population >2 million); a regional area 775 km north from the main city (population 83,225); rural and remote regions (seven communities ranging in size from 1,000 people to 15,281). These geographical areas were targeted because they represent the typical clinical referral route for CVD patients in the province.
We used qualitative methodology, employing a constructivist approach [
A purposive sample was drawn from primary and secondary care providers working in the following three settings to reflect typical referral paths for rural patients in the Northern British Columbia: (1) a tertiary care hospital in the Vancouver Metropolitan area; (2) two regional/outlying hospitals that (a) are geographically isolated from the Vancouver Metropolitan area, (b) have no in-hospital cardiac rehabilitation/heart failure management programs, and (c) routinely refer patients to the tertiary care hospital above; (3) rural communities within the service areas of the two regional hospitals. Patient participants were drawn from patients with CVD who had moved across this referral network to access care. Potential participants were identified from case files of patients referred from the two regional hospitals to the tertiary care hospital for CVD diagnosis and management and screened to ensure more than one year’s experience with CVD for all participants and involvement of at least two different health professionals in different geographical settings with each patient. Experience with CVD varied widely, with urban referral cardiologists having the highest volume of CVD patients. The regional and rural practitioners from necessity have a more varied case mix and a lower overall volume of CVD patients. However, in a rural or regional context, the volume of patients is less important than the signal from the healthcare community that this is the usual caregiver of these patients in this context. All patients were drawn from rural or regional settings without access to cardiac rehabilitation programs close to home and had moved geographically across the referral network in order to access specialized care and services.
Potential participants were either sent an email letter describing the study and requesting their participation or approached in person. Consenting individuals underwent an initial short screening interview to determine their appropriateness for participation in the study. Selection criteria limited participation to patients who were English speaking and over 19 years of age, and did not have any mental impairment. We made a particular effort to recruit female patients, but the proportion in our study is realistic, given the proportion of males to females in patients who access care at a tertiary care referral centre. A total of 48 participants were interviewed from four different groups: (a) patients (
Demographic and geographic data.
Category | Participant group | Urban | Regional | Rural | Totals | Category totals |
---|---|---|---|---|---|---|
Physicians | General practitioners | 0 | 2 | 4 | 6 | 11 |
Cardiologists | 3 | 0 | 0 | 3 | ||
Internists | 0 | 1 | 1 | 2 | ||
Nurses | Registered nurse | 1 | 2 | 2 | 5 | 13 |
Clinical nurse specialist | 6 | 0 | 0 | 6 | ||
Community health | 0 | 0 | 1 | 1 | ||
Nurse practitioner | 1 | 0 | 0 | 1 | ||
Allied health professionals | Dieticians | 2 | 2 | 1 | 5 | 10 |
Physical therapists | 0 | 2 | 0 | 2 | ||
Psychologists | 2 | 0 | 0 | 2 | ||
Social workers | 1 | 0 | 0 | 1 | ||
Patients | Male | 0 | 5 | 6 | 11 | 12 |
Female | 0 | 1 | 0 | 1 |
Patient participant characteristics.
ID | Sex | Age | Education | Cardiac disease history | Recruited from |
---|---|---|---|---|---|
1 | Male | 71 | High school | Coronary artery disease | Community hospital |
2 | Male | 71 | Postsecondary | Myocardial infarction | Community hospital |
3 | Male | 71 | Some postsecondary | Coronary artery disease | Community hospital |
4 | Male | 86 | High school | Coronary artery disease | Community hospital |
5 | Male | 69 | Postsecondary | Myocardial infarction | Community hospital |
6 | Male | 78 | Some postsecondary | Myocardial infarction | Community hospital |
7 | Male | 67 | High school | Myocardial infarction | Regional hospital |
8 | Male | 56 | Postsecondary | Myocardial infarction | Regional hospital |
9 | Male | 57 | Postsecondary | Atrial fibrillation and heart failure | Regional hospital |
10 | Male | 62 | Less than high school | Hypertension and atrial fibrillation | Regional hospital |
11 | Female | 55 | Less than high school | Coronary artery disease | Regional hospital |
12 | Male | 67 | No response | Myocardial infarction | Regional hospital |
The researchers developed an interview framework through consultation with key health authority decision makers as well as cardiologists and internists who have experience in the comanagement of patients with CVD. The interview was designed to elicit actual experiences and resulting opinions about CVD comanagement, patient self-management, and the potential role of an internet-based platform. Specifically, our interest was in how the Internet could be used to support communication among patients, physicians, and allied healthcare professionals to improve the care of patients with CVD. We envisioned developing these programs to provide cardiac rehabilitation, support heart failure management, and allow the patients to share their progress, signs, and symptoms with a nurse case-manager in charge of their daily care. Physicians would also have the ability to interact with their patient and view progress as well, and the nurse was to communicate with the physician when needed. As themes and ideas emerged in the interviews, they were explored through probing question in subsequent interviews. Interviews were semistructured and informal, allowing the researcher to solicit further information on new areas identified by the participant. Two research assistants underwent a full day of training to standardize interview questions and probes and met regularly during data collection to discuss emerging findings and construct new questions and probes. All interviews were conducted either face-to-face or by telephone, audio-recorded, and transcribed.
The qualitative interviews resulted in 447 pages of data. An iterative approach to data analysis was taken, employing a constant comparative method as a way to explore subjective experience [
Interview transcripts were analyzed in three stages by the lead author (S. Jarvis-Selinger) and a research assistant. In the first stage, all transcripts were read over repeatedly and open coding was performed to identify and label important concepts grounded in the data that were relevant to the study. Once open coding was complete, we revisited the transcripts and continued coding based on our key interview questions. This ensured that our process was open to new ideas and concepts but also relied on the work done to construct the interview questions with key stakeholders. In the second stage, the comments pertaining to these concepts were arranged in a Microsoft Excel table in order to compare the similarities and differences and group similar concepts together to establish categories and subcategories. We were particularly interested in similarities and differences across participant groups and across practice contexts. Once the table was completed, the identified categories were linked together to summarize the information into a set of common themes.
Based on the guiding research questions, the results were organized and analyzed in three central themes: (1) the role of technology for CVD management by providers and patients, (2) challenges to technology adoption, and (3) facilitators and incentives for technology adoption. Table
Challenges and opportunities.
Physicians | Nurses | Allied health | Patients | |
---|---|---|---|---|
Comanagement and the role of technology: challenges | ||||
Communication between health care workers | + | + | + | N/A |
Reconciliation of conflicting opinions | + | + | + | N/A |
Variation in decisions/treatments | + | + | + | N/A |
Team dynamics, sorting out “who’s in charge?” | + | + | N/A | |
Finding time to meet/time management | + | + | N/A | |
Geographic distances separating team members | + | N/A | ||
Lack of physician time and buy-in | + | N/A | ||
Comanagement and the role of technology: opportunities | ||||
Better communication between health care workers | + | + | + | N/A |
Sharing patient records | + | + | + | N/A |
Timely access to accurate information | + | N/A | ||
Self-management and the role of technology: challenges | ||||
Lack of experience with the internet | + | + | + | + |
Understanding the potential for such a platform | + | + | + | + |
Potential for conflicting advice | + | + | + | |
Self-management and the role of technology: opportunities | ||||
Goal setting and tracking for patients | + | + | + | + |
Accurate educational resources online for patients | + | + | + | |
Creating support for patient discussions and activities and peer support | + | |||
Identification of available outpatient resources near patient’s home | + | |||
Connecting with health professionals | + | |||
Technology adoption: challenges | ||||
Maintenance of the privacy, security, and confidentiality of digital information | + | + | + | + |
Amount of time and educational support for technology uptake/tech literacy | + | + | ||
Infrastructure needs/lack of computers | + | + | ||
Financial costs | + | |||
Accuracy of information | + | |||
Human resource needs | + | |||
Lack of interest in using computers | + | |||
Preference for face-to-face contact | + | |||
Increased anxiety as a result of excess tracking | + | |||
Technology adoption: facilitators and incentives | ||||
Provision of training | + | + | ||
Observation of positive patient changes | + | + | ||
Improvement in communication | + | + | ||
Time and cost saving | + | + | ||
Availability of high-quality resources | + | |||
Support ease of access | + | |||
Involvement in design and implementation | + | |||
Patient education and resources | + | |||
Inclusion of systems to self monitor | + | |||
Ease of use | + |
Healthcare providers and patients spoke about existing CVD management activities, their associated challenges, and the role that technology could play, highlighting both comanagement and self-management activities as well as communication processes. Although there was little difference in findings along geographical lines, the description of the health professionals included in the comanagement team differed according to whether they were located in a rural or urban centre.
Overall, the most commonly cited challenges to comanagement, identified across all health care provider groups, involved effective communication and the reconciliation of conflicting opinions (see Table
From a discussion of these challenges, more than half of all health professional groups felt that the most important application of technology was to share patient health records, thus promoting timely and accurate access to information. Physicians further described the ability to electronically access patient and provider data in a timely manner as an important means of improving comanagement communication processes. As one physician noted regarding provider data, “
Physicians’ suggestions for the improvement of CVD self-management included both patient- and provider-focused strategies (see Table
The creation of such an Internet-based program described above was felt to be of use by all involved. For example, 21 health professionals, including all nurses and allied health professionals and five out of six general practitioners, indicated that they would use such a system. Three out of five specialists indicated that they would use such a system, while the remaining two said maybe. In addition, two-thirds of the patients stated they would be either willing to use or very interested in using aspects of an Internet-based self-management system. However, there were some concerns raised that would need to be addressed prior to implementation of an Internet-based program. Not all of these concerns were directly related to technology itself but included concerns that a program supporting patient comanagement may have the potential for leading to conflicting advice being passed onto the patient causing confusion. As well, both healthcare providers and patients were limited in their ideas about what a useful platform might consist of, citing their lack of experience with the Internet as a modality for healthcare provision as a limitation.
Health providers and patients discussed challenges related to technology adoption (see Table
For example, patients identified a lack of interest in using computers as the main barrier to technology adoption. For example on patient said, “
Health professionals and patients discussed incentives that may address the identified challenges and support the use of technology for CVD management (see Table
Half of the 12 patients commented on incentives that may support patient technology use. Of these, five felt that an important incentive would be to provide useful resources to patients, including patient education and easy-to-use software that could help support the tracking/monitoring of diet, exercise, and vital signs. For example, when speaking about possible technology uses, one patient talked about tracking capabilities: “
Our study explored the perceptions of health professionals and patients about the potential role of an Internet-based platform in the management of CVD. We found that many opinions about the use of an Internet-based platform to support treatment of patients with CVD depended on the role of the interviewee (i.e., physician, nurse, allied health, or patient). These opinions did not necessarily contradict each other, but in some cases were complimentary. For example, nurses felt that physicians did not commit the time to participate to traditional comanagement opportunities, while physicians as well as allied health professionals felt that time savings would be the most effective incentive for using technology to support comanagement. However, it was noted that tensions between the health professionals’ desire to provide expert advice and the patients’ desire to manage their own health have the potential to disenfranchise one group or the other in a CVD management program designed for both. This would indicate that taking into account the needs and perspective of each person involved in patient management is essential to developing a “program” that can meet the needs of all involved. This feedback reflects the promotion by British Columbia’s Ministry of Health Services of using a modified chronic care model adapted from the Chronic Disease Management Model described by Wagner et al. [
Two concerns commonly expressed were the accuracy of patient self-reported data and security. These responses are consistent with findings in other studies [
Geographical distance created barriers for effective communication between health providers managing the same patient. It remains to be seen whether an Internet-based program can address these barriers to enable team functioning. If such a platform is to be used by providers and patients in both rural and urban settings, customization of the networks created within the management system will be important to ensure that the program is intuitive for practitioners irrespective of geographical setting and roles of team members in different settings.
We were also struck by the degree to which both healthcare professionals and patients visualized an Internet-based platform for a CVD management system in terms of recreation of the current operations. Discharge summaries arriving late by mail, weights and exercise tracked by pen and paper, and phone discussions between family physicians and specialists could be facilitated by technology. However, there is little vision of the potential for transformation of care through technology for example, distance monitoring of patients living at home; group support for patients isolated in rural areas; 24/7 connection for patients to enable them to focus on their health beyond a 15-minute annual interaction with a health professional. Our participants cited their lack of experience with an Internet-based platform as a limitation to their understanding and ideas: this is a significant barrier to the development of a truly useful and innovative platform. The potential of the Internet to transform processes, to track discussions, or to provide asynchronous group conversation were largely ignored in favour of a recreation of current operational systems. The tension between engagement of the users in the design of a platform and the potential limitations of this engagement emerged from our findings. The consideration of a design-based research approach in the development of such platforms may mitigate this tension [
A possible limitation of our study was selection bias in our participants, in that we might have recruited only participants with a keen interest in Internet-based platforms; however, we think that this was not borne out by our results. Additionally, some participants may have had too limited experience with either the Internet or other ICT to be able to consider possible uses. This is a significant limitation with our patient participants, but unavoidable with older patients, and a realistic representation of the broader community of patients. Our study took place in one province, potentially limiting its generalizability to other settings. However, a strength of our study was the sampling strategy, which sampled both diverse healthcare providers as well as patients along a usual referral route from rural communities to the regional referral centre and tertiary care urban centre, incorporating all potential users of an Internet-based platform. While the samples within each participants group were not large, qualitative research seeks to explore questions, revealing hypotheses for further testing. The multiple points of view of the research team led to rich discussion and interpretation of the findings.
Healthcare has been notoriously slow to engage in technology that transforms business processes, and yet health is the fastest growing sector of the Internet [
Our results suggest that both health care providers and patients supported the use of Internet-based technology support for CVD management, with the greatest benefit for sharing of patient data and supporting patient self-management and comanagement and with the provision of ensuring security and privacy of data. These findings are consistent with the majority of reports in the literature using Internet-based technology for CVD and other chronic disease care [
While this study was conducted within Canada in the context of a public health care system, we believe our results to be of value and can be readily translated within other health care systems. Overall, technology supported CVD management has the potential to create positive changes to the health of patients regardless to their geographical location.
The authors would like to thank the health professionals and patients who participated in this study for their frank and candid contributions. They would also like to thank Ms. Sarah Dobson for helping them edit the paper. Scott Lear holds the Pfizer/Heart and Stroke Foundation Chair in Prevention Research at St. Paul’s Hospital and is a Canadian Institute for Health Research New Investigator. S. Jarvis-Selinger holds a Michael Smith Foundation for Health Research Scholar Award. The BC Medical Services Foundation under the Vancouver Foundation provided funding for the study.