Personas for Better Targeted eHealth Technologies:User-Centered Design Approach

BACKGROUND: The full potential of eHealth technologies to support self-management and disease management for patients with chronic diseases is not being reached. A possible explanation for these lacking results is that during the development process, insufficient attention is paid to the needs, wishes, and context of the prospective end users. To overcome such issues, the user-centered design practice of creating personas is widely accepted to ensure the fit between a technology and the target group or end users throughout all phases of development. OBJECTIVE: In this study, we integrate several approaches to persona development into the Persona Approach Twente to attain a more holistic and structured approach that aligns with the iterative process of eHealth development. METHODS: In 3 steps, a secondary analysis was carried out on different parts of the data set using the Partitioning Around Medoids clustering method. First, we used health-related electronic patient record data only. Second, we added person-related data that were gathered through interviews and questionnaires. Third, we added log data. RESULTS: In the first step, 2 clusters were found, with average silhouette widths of 0.12 and 0.27. In the second step, again 2 clusters were found, with average silhouette widths of 0.08 and 0.12. In the third step, 3 clusters were identified, with average silhouette widths of 0.09, 0.12, and 0.04. CONCLUSIONS: The Persona Approach Twente is applicable for mixed types of data and allows alignment of this user-centered design method to the iterative approach of eHealth development. A variety of characteristics can be used that stretches beyond (standardized) medical and demographic measurements. Challenges lie in data quality and fitness for (quantitative) clustering

Patterns in the Use of Heart Failure Telemonitoring: Post Hoc Analysis of the e-Vita Heart Failure Trial

BACKGROUND: Research on the use of home telemonitoring data and adherence to it can provide new insights into telemonitoring for the daily management of patients with heart failure (HF). OBJECTIVE: We described the use of a telemonitoring platform-including remote patient monitoring of blood pressure, pulse, and weight-and the use of the electronic personal health record. Patient characteristics were assessed in both adherent and nonadherent patients to weight transmissions. METHODS: We used the data of the e-Vita HF study, a 3-arm parallel randomized trial performed in stable patients with HF managed in outpatient clinics in the Netherlands. In this study, data were analyzed from the participants in the intervention arm (ie, e-Vita HF platform). Adherence to weight transmissions was defined as transmitting weight ≥3 times per week for at least 42 weeks during a year. RESULTS: Data from 150 patients (mean age 67, SD 11 years; n=37, 25% female; n=123, 82% self-assessed New York Heart Association class I-II) were analyzed. One-year adherence to weight transmissions was 74% (n=111). Patients adherent to weight transmissions were less often hospitalized for HF in the 6 months before enrollment in the study compared to those who were nonadherent (n=9, 8% vs n=9, 23%; P=.02). The percentage of patients visiting the personal health record dropped steadily over time (n=140, 93% vs n=59, 39% at one year). With univariable analyses, there was no significant correlation between patient characteristics and adherence to weight transmissions. CONCLUSIONS: Adherence to remote patient monitoring was high among stable patients with HF and best for weighing; however, adherence decreased over time. Clinical and demographic variables seem not related to adherence to transmitting weight. TRIAL REGISTRATION: ClinicalTrials.gov NCT01755988; https://clinicaltrials.gov/ct2/show/NCT01755988

Patterns in the Use of Heart Failure Telemonitoring:Post Hoc Analysis of the e-Vita Heart Failure Trial

Background: Research on the use of home telemonitoring data and adherence to it can provide new insights into telemonitoring for the daily management of patients with heart failure (HF). Objective: We described the use of a telemonitoring platform—including remote patient monitoring of blood pressure, pulse, and weight—and the use of the electronic personal health record. Patient characteristics were assessed in both adherent and nonadherent patients to weight transmissions. Methods: We used the data of the e-Vita HF study, a 3-arm parallel randomized trial performed in stable patients with HF managed in outpatient clinics in the Netherlands. In this study, data were analyzed from the participants in the intervention arm (ie, e-Vita HF platform). Adherence to weight transmissions was defined as transmitting weight ≥3 times per week for at least 42 weeks during a year. Results: Data from 150 patients (mean age 67, SD 11 years; n=37, 25% female; n=123, 82% self-assessed New York Heart Association class I-II) were analyzed. One-year adherence to weight transmissions was 74% (n=111). Patients adherent to weight transmissions were less often hospitalized for HF in the 6 months before enrollment in the study compared to those who were nonadherent (n=9, 8% vs n=9, 23%; P=.02). The percentage of patients visiting the personal health record dropped steadily over time (n=140, 93% vs n=59, 39% at one year). With univariable analyses, there was no significant correlation between patient characteristics and adherence to weight transmissions. Conclusions: Adherence to remote patient monitoring was high among stable patients with HF and best for weighing; however, adherence decreased over time. Clinical and demographic variables seem not related to adherence to transmitting weight.</p

Hemichannel-Mediated and pH-Based Feedback from Horizontal Cells to Cones in the Vertebrate Retina

Background: Recent studies designed to identify the mechanism by which retinal horizontal cells communicate with cones have implicated two processes. According to one account, horizontal cell hyperpolarization induces an increase in pH withinthe synaptic cleft that activates the calcium current (Ca2+-current) in cones, enhancing transmitter release. An alternative account suggests that horizontal cell hyperpolarization increases the Ca2+-current to promote transmitter release through ahemichannel-mediated ephaptic mechanism.Methodology/Principal Findings: To distinguish between these mechanisms, we interfered with the pH regulating systems in the retina and studied the effects on the feedback responses of cones and horizontal cells. We found that the pH buffers HEPES and Tris partially inhibit feedback responses in cones and horizontal cells and lead to intracellular acidification ofneurons. Application of 25 mM acetate, which does not change the extracellular pH buffer capacity, does lead to both intracellular acidification and inhibition of feedback. Because intracellular acidification is known to inhibit hemichannels, the key experiment used to test the pH hypothesis, i.e. increasing the extracellular pH buffer capacity, does not discriminatebetween a pH-based feedback system and a hemichannel-mediated feedback system. To test the pH hypothesis in a manner independent of artificial pH-buffer systems, we studied the effect of interfering with the endogenous pH buffer, the bicarbonate/carbonic anhydrase system. Inhibition of carbonic anhydrase allowed for large changes in pH in the synapticcleft of bipolar cell terminals and cone terminals, but the predicted enhancement of the cone feedback responses, according to the pH-hypothesis, was not observed. These experiments thus failed to support a proton mediated feedback mechanism. The alternative hypothesis, the hemichannel-mediated ephaptic feedback mechanism, was therefore studied experimentally, and its feasibility was buttressed by means of a quantitative computer model of the cone/horizontal cellsynapse.Conclusion: We conclude that the data presented in this paper offers further support for physiologically relevant ephaptic interactions in the retina

Synaptic Transmission from Horizontal Cells to Cones Is Impaired by Loss of Connexin Hemichannels

In the vertebrate retina, horizontal cells generate the inhibitory surround of bipolar cells, an essential step in contrast enhancement. For the last decades, the mechanism involved in this inhibitory synaptic pathway has been a major controversy in retinal research. One hypothesis suggests that connexin hemichannels mediate this negative feedback signal; another suggests that feedback is mediated by protons. Mutant zebrafish were generated that lack connexin 55.5 hemichannels in horizontal cells. Whole cell voltage clamp recordings were made from isolated horizontal cells and cones in flat mount retinas. Light-induced feedback from horizontal cells to cones was reduced in mutants. A reduction of feedback was also found when horizontal cells were pharmacologically hyperpolarized but was absent when they were pharmacologically depolarized. Hemichannel currents in isolated horizontal cells showed a similar behavior. The hyperpolarization-induced hemichannel current was strongly reduced in the mutants while the depolarization-induced hemichannel current was not. Intracellular recordings were made from horizontal cells. Consistent with impaired feedback in the mutant, spectral opponent responses in horizontal cells were diminished in these animals. A behavioral assay revealed a lower contrast-sensitivity, illustrating the role of the horizontal cell to cone feedback pathway in contrast enhancement. Model simulations showed that the observed modifications of feedback can be accounted for by an ephaptic mechanism. A model for feedback, in which the number of connexin hemichannels is reduced to about 40%, fully predicts the specific asymmetric modification of feedback. To our knowledge, this is the first successful genetic interference in the feedback pathway from horizontal cells to cones. It provides direct evidence for an unconventional role of connexin hemichannels in the inhibitory synapse between horizontal cells and cones. This is an important step in resolving a long-standing debate about the unusual form of (ephaptic) synaptic transmission between horizontal cells and cones in the vertebrate retina

Exploring How Professionals Within Agile Health Care Informatics Perceive Visualizations of Log File Analyses: Observational Study Followed by a Focus Group Interview

Background: An increasing number of software companies work according to the agile software development method, which is difficult to integrate with user-centered design (UCD) practices. Log file analysis may provide opportunities for integrating UCD practices in the agile process. However, research within health care information technology mostly has a theoretical approach and is often focused on the researcher’s interpretation of log file analyses. Objective: We aimed to propose a systematic approach to log file analysis in this study and present this to developers to explore how they react and interpret this approach in the context of a real-world health care information system, in an attempt to answer the following question: How may log file analyses contribute to increasing the match between the health care system and its users, within the agile development method, according to agile team members? Methods: This study comprised 2 phases to answer the research question. In the first phase, log files were collected from a health care information system and subsequently analyzed (summarizing sequential patterns, heat mapping, and clustering). In the second phase, the results of these analyses are presented to agile professionals during a focus group interview. The interpretations of the agile professionals are analyzed by open axial coding. Results: Log file data of 17,924 user sessions and, in total, 176,678 activities were collected. We found that the Patient Timeline is mainly visited, with 23,707 (23,707/176,678; 13.42%) visits in total. The main unique user session occurred in 5.99% (1074/17,924) of all user sessions, and this comprised Insert Measurement Values for Patient and Patient Timeline, followed by the page Patient Settings and, finally, Patient Treatment Plan. In the heat map, we found that users often navigated to the pages Insert Measurement Values and Load Messages Collaborate. Finally, in the cluster analysis, we found 5 clusters, namely, the Information-seeking cluster, the Collaborative cluster, the Mixed cluster, the Administrative cluster, and the Patient-oriented cluster. We found that the interpretations of these results by agile professionals are related to stating hypotheses (n=34), comparing paths (n=31), benchmarking (n=22), and prioritizing (n=17). Conclusions: We found that analyzing log files provides agile professionals valuable insights into users’ behavior. Therefore, we argue that log file analyses should be used within agile development to inform professionals about users’ behavior. In this way, further UCD research can be informed by these results, making the methods less labor intensive. Moreover, we argue that these translations to an approach for further UCD research will be carried out by UCD specialists, as they are able to infer which goals the user had when going through these paths when looking at the log data

A Priori Theory Approach to Conceptualizing Engagement with Digital Mental Health Interventions

Background: Digital Mental Health Interventions (DMHIs) show different levels of effectiveness for different people. A construct that can explain these differences is engagement. Engagement is traditionally referred to as users' behavioral, cognitive, and affective investment. Even though a holistic, dynamic, and contextual nature of engagement has been suggested, most research measures it as a monodisciplinary, narrow, and static construct. Moreover, most engagement frameworks within eHealth are often constructed by adopting variables and relationships from different fields without establishing a prior theoretical foundation. This theoretical disconnectedness can be the reason for conceptual and methodological confusion. This study aims to conceptualize engagement based on interdisciplinary theories.Method: The study followed an a priori theory approach analyzing Postphenomenology, Social Practice Theory, and Social Cognitive Theory. These theories were chosen because they reflect engagement's holistic, dynamic, and contextual nature. Based on the analysis and integration of these theories, we crafted the first version of a conceptual framework for engagement with DMHIs.Findings: The novel conceptual framework offers a process-based perspective to engagement with DMHIs by distinguishing different types of engagement: engagement states, modes, and processes. Engagement states represent different combinations of behavioral, cognitive, and affective engagement, while modes describe the specific ways individuals engage with these interventions. Engagement states and modes shape the engagement process people experience with DMHIs.Conclusion: The novel framework shows the multifaceted structure of engagement with DMHIs and calls for more nuanced methods and measures to identify different engagement states and modes. These states and modes appear as building blocks of the engagement process, and they can help us uncover the patterns of different engagement processes. The framework addresses the need for a more dynamic, holistic, and contextual conceptualization of engagement and provides future directions for a clearer understanding of engagement with DMHIs

Embedding a sustainability focus in packaging development processes

Despite packaging sustainability aspects often being embedded in companies’ strategic aims, the structured implementation of such targets is limited at the operational level, where a product’s commercial viability (strategic fit, business case feasibility, and a limitation of commercial risks) and development aspects (timing issues, material use, and supply chain efficiency) are prioritized over desired sustainability goals. Packaging acts not as an isolated entity but as a part of a symbiotic product-packaging combination, of which the development is the shared responsibility of stakeholders with different backgrounds and interests. With the development and design process of product-packaging combinations being a concatenation of decisions made by multidisciplinary teams in various organizations, the structured integration of sustainability-related considerations in product-packaging development can benefit from a synthesized focus on development teams’ efforts, decision-making processes, stakeholder interaction and dynamics, and trade-offs. This research addresses a vision on an approach to explore, understand, and analyze this field, specifically its key characteristics that act as enablers and barriers of product-packaging sustainability. This is targeted by interactively modelling the decision-making processes of product-packaging development, both within multidisciplinary development teams, companies, and product-packaging chains, by means of a collection of interactive tools. Key within these tools is the ability to address the multidisciplinarity of stakeholders, the decision-making processes within and beyond development teams, and the proposed and realized inclusion of sustainability-related considerations, all within a framework of tacit and explicit knowledge