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Table 2 Context, mechanisms and outcomes for each proposition

From: Using technology to engage hospitalised patients in their care: a realist review

Proposition 1: Information sharing allows patients to be better informed about their health condition and health care, facilitating participation in care through improved communication, patient empowerment, informed decision making, self-care and self-management.
Author, year, country Context Mechanisms Outcomes
  Setting Participants Intervention (tools/resources) Proposed action  
(Wilcox, Woollen et al. 2016) [30], USAa 30-bed post-operative cardiac unit, university hospital, New York. 20 cardio-thoracic surgery patients, mean age 58 (range 26–81) years, 40% female; and n = 2 family members. Personal health record portal accessed via iPad provided to patients. Included: patient-specific information (demographics, care providers, medication orders and records) and educational content (cardiovascular conditions, tests and procedures). Providing access to health information improves patients’ knowledge and awareness; communication with HCPs; self-care; and participation. Patient safety may be improved as patients can resolve discrepancies in data. 70% were active users (used program unsupervised). 90% found it useful. Patients liked ‘patient notepad’ for communicating with HCPs and liked ability to share information with family.
(O’Leary, Lohman et al. 2015) [27], USAb General medical units, large academic hospital in Chicago. 100 medical patients, mean age 47 years, 63% female, 44% Caucasian. Patient portal accessed via iPad provided to patients. Included: general patient information, care team, medication list and agenda for the day (i.e. mealtimes and scheduled tests and procedures). Providing access to health information improves patients’ knowledge in some areas. Unfamiliar terminology, inadequate time to review portal, lack of motivation or preferring a passive role in care may be barriers to technology. High portal use (80% used). High satisfaction (76% found it easy to use, 71% reported information was useful). Patients had greater knowledge of their doctors’ names and roles but no significant improvements in other areas.
(Cook, Moradkhani et al. 2014) [26], USAc Mayo clinic hospital 149 elective cardiac surgery patients aged >50 (mean 68) years, expected LOS 5–7 days. Patient recovery program, accessed via iPad provided by hospital. Included: hospital plan of stay, education, recovery planning, daily ‘to do’ lists, and daily self-assessment and reporting (discharge planning and mobility screening tools). Information sharing helps patients understand their condition and plan of care, which improves participation in care and self- management. High completion (84% of 6295 modules delivered were completed; mean 42 modules per patient). High understanding (90% of patients understood 90% of content before discharge).
(Greysen, Khanna et al. 2014) [24], USAd Hospital (details not reported) 30 medical patients (60% aged ≥40 years). Web-based interactive health education modules and personal health records; accessed via iPads provided to patients. Educational modules included: medication safety, handwashing, falls prevention, communicating with HCPs, discharge planning. Personal health record contained functions to view/refill medications, view /modify appointments, send messages to HCPs. Providing access to health information promotes patient engagement in discharge planning through increased knowledge about plan of care. High satisfaction (90% satisfied or very satisfied). High engagement/use of program (83% independently completed modules).
(Dykes, Carroll et al. 2013) [28], USAe General medical units in two academic medical centres 8 patients and 3 family members on general medical units, aged 37–90 (mean age 64) years. Electronic bedside communication centre accessed via internet on secure mobile tablet device provided to patients. Contained: orientation to environment (hospital, care team); schedule (events, consultations, tests, mealtimes); notes (patients/family could document questions/concerns to discuss with HCPs); and health information (medication schedule, test results, tailored education). Providing patients with information about their condition and opportunity to discuss this with HCPs is a strategy for engaging patients in their recovery plan and shared decision making. High satisfaction with program and information contained, particularly around their care (i.e. care team, medications, test results, health condition information etc.). Wanted ability to communicate with HCPs from the bedside and order meals online.
(Pfeifer Vardoulakis, Karlson et al. 2012) [15], USAf Emergency department in an urban hospital 25 patients and 8 family (mean age 46 years, 92% African-American). Private access to own information through a mobile phone (provided to patients). Contained: key events (i.e. room assignment, medication administration); profile (general and demographic information); care team (names, titles, pictures of HCPs); and medications and tests, with brief explanations of each item and ability for patients to email pages to themselves or their GP. Information sharing improves patients’ and families’ knowledge and awareness of their condition and care, which enables participation in care through empowerment, shared decision making and self-management. High usage (22 of 25 used regularly). High satisfaction; patients felt less anxious as they were more aware of their condition and care plan. They found medical explanations useful and liked sharing information with their families. Access to the phone helped them remember details they would otherwise forget.
(Vawdrey, Wilcox et al. 2011) [16], USA Step-down cardiology unit at a large urban academic medical centre 5 male patients (mean age 55, mean LOS 5 days) and one spouse. Personal health record portal accessed through iPad (provided to patients). Contained personal health information (demographics, HCPs, medication orders); information to help patients understand their conditions, tests and procedures; and information targeted at cardiovascular health. Sharing of health information via iPads enables participation in care through increased knowledge, adherence and shared decision making. Patients were satisfied and felt engaged in care process. They perceived the program to be useful; liked ability to review information at own pace; felt more connected with team; felt less burdened to remember details of admission; liked to review accuracy of information in electronic record.
Proposition 2: Self-assessment and feedback enhances patient learning through interactivity, embedding of knowledge and relevance and specificity of information provided. This learning results in increased patient empowerment and responsibility in their care and improved communication between patients and HCPs, which facilitates patient participation in care.
(Tzeng, Yin et al. 2015) [31], USAg Adult subacute stroke rehab inpatient unit. 5 patients aged ≥65 years (falls risk) Web-based software application accessed through an android tablet device (provided to patients). Contained: inpatient fall risk assessment; set of approaches and tasks selected by patients, that they can do themselves to prevent falls; ability to create individualised falls prevention plan for printing. Self-assessment of falls risk helps patients understand their own risk factors. Self-selection of tasks patients can do themselves to minimise each risk factor helps them to make decisions to reduce falls risk. This empowers patients to be informed, active and collaborative partners in their care. Patients liked the design of Patients liked the design of iEngaging as (1) an easy to use and effective tool; (2) allowing patient to tailor falls prevention and self-management care plan; (3) giving patient a voice and facilitating increased communication with health care providers.
(Cook, Manning et al. 2013) [32], USAh Mayo clinic hospital 149 elective cardiac surgery patients aged >50 (mean 68) years, expected LOS 5–7 days. Patient recovery program, accessed via iPad provided by hospital. Included: hospital plan of stay, education, recovery planning, daily ‘to do’ lists, and daily self-assessment and reporting (discharge planning and mobility screening tools). Patient self-assessment and self-reporting, integrated into an individualised plan for hospital recovery, increases patients’ responsibility for a shared plan of care; facilitates patient input into care; and enables patients to actively participate in their care. High completion rates: 1,384 of 1,418 self-assessment modules delivered to 149 patients were completed (97.6%).
(Oosterom-Calo, Abma et al. 2014) [23], UK i Cardiology ward at a UK academic hospital. 7 male heart failure patients aged 37–76. Motivate4Change: interactive health promotion program, accessed via a tablet computer (provided to patient). Contained introduction, medication adherence and physical activity modules. Each module contained: introduction, list of key messages, video with information on each topic, showing a ‘typical’ heart failure patient dealing with issues (i.e. role modelling), and assessments and feedback. Self-assessments of knowledge, barriers and beliefs around medication adherence and physical activity allow for tailored feedback messages that are targeted and relevant to patients, and hence more likely to be acceptable and perceived as useful. Patients enjoyed interactive learning and felt it better addressed their learning needs. Patients appreciated receiving targeted information and felt their personal situations were acknowledged through the assessments and feedback, which seemed to encourage them to perform healthy behaviours.
(Ruland, Holte et al. 2010) [29], Norway Norwegian university hospital. 145 patients starting leukaemia/ lymphoma treatment, mean age 49–50 years. Interactive module on iPad (provided to patients) where patients could communicate symptoms, concerns, problems to HCPs and prioritise these. Tailored questions and recommendations given based on patients’ initial responses. Patient-completed assessments of symptoms, problems and concerns, which are prioritised and then shared with HCPs, enables patient empowerment and participation in care through improved communication with HCPs and shared care planning. Intervention group: significantly more symptoms and problems addressed by HCPs; greater reductions in symptoms distress; greater reduction in need for symptom management support compared to control.
Proposition 3: Patients are more accepting of, engaged in and satisfied with education that is tailored to reflect their personal situation and information needs, as information is perceived to be useful and relevant. Knowledge gained through engaging in tailored education empowers patients to take greater responsibility for and participate in their care.
(Cook, Moradkhani et al. 2014) [26] cAs above cAs above Tailored education helps patients understand their condition and plan of care, and identify and manage potential complications; and is a means to increased self-management, adherence and satisfaction. Education and recovery planning modules, tailored to patients’ surgery and medical conditions, empowers patients to share ownership of and participate in care. 5,267 of 6295 education modules (84%) delivered to 149 patients were completed (mean 42 ± 3 modules completed per patient). Completion rates were higher in men than women, but were not associated with age. 90% of patients indicated they understood 90% of the content prior to discharge.
(Oosterom-Calo, Abma et al. 2014) [23] iAs above iAs above Education tailored to patients’ existing knowledge, barriers and beliefs; needs and preferences; medical condition and personal situation is more likely to be relevant, useful and acceptable to patients. Patients are more likely to adhere to the self-management strategies learned if they perceive them to be relevant, useful and acceptable. Patients had high levels of satisfaction; thought the program was contextual, empathic and relevant to their life and situation. They felt encouraged, motivated and comforted by the program. They appreciated receiving less information that was more specific and relevant to them; however all patients read all of the information provided, with some expressing a positive attitude towards learning.
(Bickmore, Mitchell et al. 2010) [21], USA j Urban academic safety net hospital 131 patients (19 with major depressive condition), mean age 46–49. Computer-animated conversational agent (virtual nurse) accessed via a wheeled kiosk with a touchscreen. Provides information prior to hospital discharge on: post-discharge care regimen (medications, follow up appointments, exercise and diet, test results), supplemented with a booklet. Education about patients’ diagnosis and post discharge self-care regimen, tailored to patients’ medical conditions, health literacy and empathic needs, is more likely to be understood, acceptable and useful to patients with special needs (i.e. with low health literacy or depressive symptoms). When patients understand information and find it to be acceptable and useful, they are more likely to use it. Very high reported satisfaction, ease of use and attitudes towards agent. Only 24% of patients would have preferred information from doctor or nurse. Appreciated amount of time the agent spent with them. Patients with inadequate health literacy and major depressive symptoms reported a greater therapeutic alliance with the agent than patients with adequate health literacy and no depressive symptoms.
(Bickmore, Pfeifer et al. 2009) [21], USAk 3 inpatient floors of a medical centre. 19 patients, 53% female, aged 25–75 (mean age 55), 42% with inadequate health literacy. Computer-animated conversational agent (virtual nurse) accessed via a wheeled kiosk with a touchscreen. Provides information prior to hospital discharge on: post-discharge care regimen (medications, follow up appointments, exercise and diet, test results), supplemented with a booklet. Education about patients’ diagnosis and post discharge self-care regimen, tailored to patients’ medical condition and health literacy, enables patient participation in care by empowering them (through increased knowledge) to self-manage their own health. This increased knowledge also empowers patients to communicate with HCPs and engage in shared decision making. All participants completed interaction with no problems. Patients were highly satisfied and found it easy to use, informative, and useful/helpful. Patients felt comfortable receiving health information from a computer and reported they would follow advice given by virtual nurse. Patients appreciated amount of information and time given by virtual nurse (i.e. more than HCPs provide). 60% of patients chose to hear additional details/cover more content. Patients felt empowered by the information they received.
Proposition 4: A user-centred design, that is, incorporating user perspectives (such as patients and clinicians) in the design of HIT aiming to engage patients in their hospital care is essential for developing programs that meet patients’ information and learning needs that are also acceptable to and used by patients. If end-users are involved in design and development of HIT, they are more likely to be engaged in using the program, as it is relevant and acceptable to them.
Author, year, country Context Mechanisms* Outcomes
(Wilcox, Woollen et al. 2016) [30] aAs above A user-centred process of aligning program design with information needs of cardio-thoracic surgery patients and ensuring interaction and presentation techniques of the tools match abilities and preferences of target population maximise patient satisfaction, acceptability and use of the program. Patients had high levels of satisfaction (90% were satisfied) and use (70% were active users) and found the program useful and easy to use.
(O’Leary, Lohman et al. 2015) [27] bAs above Patients’ preferred content for the portal was identified in a prior study; but no mechanism was described for how this related to outcomes. bAs above; but not linked with mechanisms of user-centred design.
(Oosterom-Calo, Abma et al. 2014) [23] iAs above A user-centred design approach incorporating user perspectives, needs and preferences is essential for patients to actually use the system, and for it to be successful. Patients had high levels of satisfaction and thought the program was contextual, empathic and relevant to them. They felt the information provided met their needs.
(Dykes, Carroll et al. 2013) [28] eAs above An iterative participatory software development process was used, incorporating end-user needs and perspectives, which was proposed to enhance patients’ understanding and use of the technology. Patients were highly satisfied the program and information it contained, particularly around their care team, medications, test results and health information.
(Pfeifer Vardoulakis, Karlson et al. 2012) [15] fAs above Authors assessed basic usability and intuitiveness of HIT design and conducted a pilot study to gain user feedback, which was incorporated into end design; however no mechanism was described for how this may lead to outcomes. fAs above; but not linked with mechanisms of user-centred design.
Proposition 5: Supporting patients in the use of HIT, including familiarisation, training and ongoing support is critical to patients’ acceptance, engagement and use of this technology. Patients acknowledge that both HCPs and HIT have unique but complementary roles, and both are important for enabling participation in care.
Author, year, country Context Mechanisms* Outcomes
(Wilcox, Woollen et al. 2016) [30] aAs above 15 min training and observations session was provided; however no mechanism was described for how this may lead to outcomes. aAs above; but not linked with mechanisms of support in HIT use.
(O’Leary, Lohman et al. 2015) [30] bAs above Patients were given a brief orientation to the program and given contact information for one-on-one support; however no mechanism was described for how this may lead to outcomes. bAs above; but not linked with mechanisms of support in HIT use.
(Tzeng, Yin et al. 2015) [31] gAs above Patients were given 5 min orientation; however no mechanism was described for how this may lead to outcomes. Patients liked the design of the program but desired time to review the content with a HCP or family member, and desired additional instructions or directions about using the program.
(Cook, Manning et al. 2013) [32] hAs above Patients were instructed on program use by nurses (no further details given); however no mechanism was described for how this may lead to outcomes. hAs above; but not linked with mechanisms of support in HIT use.
(Greysen, Khanna et al. 2014) [24] dAs above Patients received a tiered orientation tailored to individual experience and needs; however no mechanism was described for how this may lead to outcomes. dAs above; but not linked with mechanisms of support in HIT use.
(Oosterom-Calo, Abma et al. 2014) [23] iAs above Support from HCPs, including explaining the purpose of the program and how to use it, could reduce patient insecurity in using the program and ensure patients are ready and able to participate. Patients found the program easy to use; even those who expressed negative attitudes towards HIT, however still sought support from others in its use.
(Pfeifer Vardoulakis, Karlson et al. 2012) [15] fAs above Patients were given a brief (2–4 min) tutorial about the program; however no mechanism was described for how this may lead to outcomes. fAs above; but not linked with mechanisms of support in HIT use.
(Bickmore, Mitchell et al. 2010) [21] jAs above A brief training session was provided to patients; however no mechanism was described for how this may lead to outcomes. jAs above; but not linked with mechanisms of support in HIT use.
(Bickmore, Pfeifer et al. 2009) [21] kAs above A brief training session was provided to patients; however no mechanism was described for how this may lead to outcomes. kAs above; but not linked with mechanisms of support in HIT use.
  1. GP General practitioner, HCP Health care professional, HIT Health information technology, LOS Length of stay
  2. *Intervention has been described earlier, so ‘Mechanisms’ refers only to mechanisms of action proposed by authors