The Online Patient Provider Communication service (OPPC) in the study is an Internet-based system where patients can send messages to and receive answers from hospital nurses, physicians, nutritionists and social workers. The message from the patient is received in the mailbox of the coordinating nurse, who has expertise on the respective diagnoses and treatments, and has access to the patients' medical record at the hospital. The nurse can address the question directly, or forward the message to the mail box of another provider who is in a better position to answer the question.
The OPPC was implemented at five different units at a university hospital, and offered to patients who had one of five diagnoses or treatments: 1) Liver transplantation, 2) Testicular cancer, 3) Autologous stem cell transplantation, 4) Advanced cancer and participating in a clinical drug trial, or 5) Type 1 diabetes. The study is completed at all five units, and has provided us with more than 200 study patients.
Online communication is a potential means of communication between patients and health care providers. We have explored how the OPPC could meet the information needs of men with newly diagnosed testicular cancer. We examined the content of online messages sent by 12 patients in addition to conducting individual interviews with five of them. Four themes became distinct: 1) the OPPC is a means for managing illness-related concerns at home, 2) ensuring information flow, 3) strategic information seeking, and 4) not yet available when needed most. Individualized information provided by nurses was shown to be important to these patients. The findings of this study indicate that not only may access to an OPPC help patients fulfill their otherwise unmet information needs, but also it may prevent delays and discontinuity in care due to informational gaps and lead to improved patient safety. The results showed also that the OPPC enabled the nurses to support patients between the patients' hospital visits and expanded nurses' ability to exercise patient-centered care.
Knowledge about patient barriers to use OPPCs is valuable information when implementing OPPCs in the health care services, and can help timing, targeting and tailoring OPPCs to different groups of patients. Therefore, we interviewed 22 non-users to get knowledge about their views of the OPPC and their reported reasons for non-use of the service. The interviews revealed that the patients appreciated the availability and the possibility of using the OPPC as needed, even if they did not use it. Their reported reasons for non-use fell into three main categories: they felt that they did not need the OPPC and had sufficient access to information elsewhere; they preferred other types of communication such as telephone or face-to-face contact; or they were hindered by OPPC attributes such as log-in problems. The findings of this study indicate that OPPCs should be offered to the patients at an appropriate time in the illness trajectory, both when they need the service, and when they are receptive to information about the service, and that a live demonstration of the OPPC at the point of enrolment might have increased its use.
In the study of OPPC in the real world, we wanted to get an understanding of what is needed for successful implementation of services like OPPC to regular clinical practice. We conducted individual interviews with nurses and physicians who had answered questions from patients through OPPC. The interviews were covering implementation issues, as well as the OPPC service itself. We found that four of the units offered OPPC to most of the available patients (high reach units), while the fifth unit offered OPPC to only a few patients (low reach unit). The interviews revealed that the institutional factors, such as structural characteristics of the units, culture, implementation climate and available resources, are of particular importance for implementation in the given context. Also health care providers' belief in the intervention as useful for themselves and the patients as well as the conduct of the implementation process and engagement of key personnel were identified for implementation success of OPPC.
As a framework for the implementation study in the project, we used the Consolidated Framework for Implementation Research (CFIR). We used CFIR to identify distinguishing factors between high and low reach units, and we compared CFIR-constructs derived from our study with CFIR-constructs derived from other studies. In this way we made an important contribution to the refinement of CFIR to be a more succinct, parsimonious framework for planning and evaluation of clinical interventions across settings and interventions.
A growing research literature documents the effectiveness of Internet support and online patient-provider communication (OPPC) to improve patient-centred care and health outcomes. However, lack of knowledge and attention to factors important to implement efficacious interventions into the organizational contexts of clinical practice hampers translation into routine practice and highlights the need for studying real world use. This international collaboration study will implement and evaluate the effects a nd use of an OPPC service as part of regular care where patients can ask questions and receive advice and support from care providers and social counsellors from NAV. In Phase I we will identify patients needs, care providers requirements, organizational infrastructure, and use participatory design methods to adapt the OPPC service to the context of clinical practice. In Phase II two sequential cohorts will be followed with 4 repeated measures over 6 months to test the effectiveness of OPPC in regular car e. Cohort 1 will receive usual care; Cohort 2 the OPPC service. We will include 130 patients per cohort. Outcome measures are: 1) participation rates and frequency of OPPC use; 2) health care utilization and cost-effectiveness of the OPPC service; 3) char acteristics of high/low volume OPPC users, patient-caregiver communication and OPPC use patterns; 4) patients and care providers perceived usefulness and ease of use; 6) impacts on organizational change and interdisciplinary collaboration, including NAV; and 6) OPPC maintenance. This study significantly contributes to the next step of research translation into practice by demonstrating and evaluating the real-world implementation of an innovative technology that can improve patient-provider communication, care quality and patient outcomes.