Implementing digital health technologies in intensive care: a mixed methods study with development of an implementation framework

Background: In the context of the digital transformation of healthcare, technologies such as tablet-based remote patient monitoring systems promise to improve patient-related outcomes and reduce workload of healthcare staff. However, the introduction of novel digital technologies into routine clinical practice, e.g. in intensive care units (ICUs), is still lagging behind. In the context of implementing a remote patient monitoring system, we aimed to explore expectations of ICU staff regarding patient monitoring, validate them, and develop an implementation framework for digital health technologies in the ICU. Methods: We followed an exploratory research approach using mixed methods. The data collection included semi-structured interviews, field visits and focus groups; and an online cross-sectional survey to validate the insights gained. We derived the implementation framework applying inductive and deductive analysis. The deduction was oriented towards the categories of the Consolidated Framework for Implementation Research and the Expert Recommendations for Implementing Change. Results: Staff expectations regarding novel patient monitoring solutions included introducing wireless sensors, enhanced usability and optimized alarm management. Many false positive alarms due to poor alarm hygiene were considered problematic, more training with new devices was demanded. In the validation study, staff members stated that high rates of false-positive alarms (n=60, 70% chose “Strongly agree” or “Agree”) and too many sensor cables (n=66, 77%) would disturb patient care. They supported using remote patient monitoring for earlier alerts (n=55, 65%) and artificial-intelligence-powered clinical decision support systems for early detection of complications (n=67, 79%). To promote usage of such systems, respondents suggested more interoperability (n=79, 93%), high usability (n=78, 93%) and more training with technologies (n=75, 90%). High quality and regular staff training, clear leadership commitment and feedback opportunities for staff should be installed for improved implementation. The presented framework compiles strategies to apply before, during and in the general context of the implementation, focussing on usability and adaptability of the intervention, staff involvement, communication, and evaluation strategies. Conclusions: The implementation of digital health technology in specialized settings like the ICU requires a high level of staff resources and commitment. It is important to test the adaptability of the technology and improve it with a user-centered approach in design and implementation. The implementation involves interdisciplinary staff engagement, clear communication of the project, and continuous assessment of implementation requirements and conditions should be continuously reassessed. The presented framework may guide implementation leaders towards sustainable and user-centered introduction of digital health technology in the ICU.Neue digitale Gesundheitstechnologien könnten patientenbezogene Out-comes verbessern und die Arbeitsbelastung des Personals reduzieren. Ihre Einführung in die klinische Routinepraxis auf Intensivstationen verläuft jedoch schleppend. Im Kontext der Implementierung eines neuen Patientenmonitoringsystems auf einer Intensivstation untersuchten wir Erwartungen des Personals an die Monitoring-Technologie, validierten sie und entwickelten ein Implementierungsframework für digitale Gesundheitstechnologien auf Intensivstationen. Methoden: Wir verfolgten einen explorativen Mixed-Methods Forschungsansatz. Die Datenerhebung umfasste semistrukturierte Interviews, Feldbeobachtungen und Fokusgruppen, die induktiv und deduktiv analysiert wurden, sowie einen Onlinefragebogen, der deskriptiv ausgewertet wurde. Das Implementierungsframework wurde induktiv und deduktiv aus der Datengrundlage heraus sowie aufbauend auf evidenzbasierten Rahmenwerken entwickelt. Ergebnisse: Das Personal wünschte sich für ein zukünftiges Patientenmonitoring drahtlose Sensoren, höhere Benutzerfreundlichkeit und ein optimiertes Alarmmanagement. Sie bewerteten viele falsch-positive Alarme problematisch und forderten mehr Training mit neuen Geräten. Auch in der Validierungsstudie wurden zu viele falsch-positive Alarme (n=60, 70% wählten "stimme voll zu" oder "stimme zu") und zu viele Sensorkabel (n=66, 77%) bemängelt. Das Personal befürwortete den Einsatz von Patientenfernüberwachung um früher alarmiert zu werden (n=55, 65%), und von durch Künstliche Intelligenz gestützte Entscheidungshilfesystemen für die Früherkennung von Komplikationen (n=67, 79%). Für eine höhere Nutzung solcher Systeme seien Interoperabilität (n=79, 93%), Benutzerfreundlichkeit (n=78, 93%) und mehr Schulungen (n=75, 90%) sinnvoll. Zur Verbesserung der Implementierung sollten qualitativ hochwertige und regelmäßige Mitarbeiterschulungen, ein klares Leitungsengagement für das Projekt und Feedbackmöglichkeiten vorhanden sein. Das Implementierungsframework für digitale Gesundheitstechnologien auf Intensivstationen enthält Strategien, die vor, während und im allgemeinen Kontext der Implementierung angewandt werden können, wobei die Benutzerfreundlichkeit und Anpassungsfähigkeit der Intervention, die Einbeziehung des Personals, die Kommunikation und die Evaluierungsstrategien im Mittelpunkt stehen. Schlussfolgerungen: Die Implementierung digitaler Gesundheitstechnologien in spezialisierten Settings wie Intensivstationen muss sorgfältig geplant werden. Im Fokus steht die Einschätzung der Anpassungsfähigkeit der Technologie, die mit nutzerzentrierten Methoden verbessert werden sollte, u.a. durch die Einbeziehung des interdisziplinären Personals und eine klare Kommunikation des Projekts. Zudem sollten Anforderungen für die Implementierung kontinuierlich neu eingeschätzt werden. Das Framework kann Verantwortlichen in der Implementierungspraxis als Leitfaden dienen

Undergraduate Medical Competencies in Digital Health and Curricular Module Development: Mixed Methods Study

Background: Owing to an increase in digital technologies in health care, recently leveraged by the COVID-19 pandemic, physicians are required to use these technologies appropriately and to be familiar with their implications on patient care, the health system, and society. Therefore, medical students should be confronted with digital health during their medical education. However, corresponding teaching formats and concepts are still largely lacking in the medical curricula. Objective: This study aims to introduce digital health as a curricular module at a German medical school and to identify undergraduate medical competencies in digital health and their suitable teaching methods. Methods: We developed a 3-week curricular module on digital health for third-year medical students at a large German medical school, taking place for the first time in January 2020. Semistructured interviews with 5 digital health experts were recorded, transcribed, and analyzed using an abductive approach. We obtained feedback from the participating students and lecturers of the module through a 17-item survey questionnaire. Results: The module received overall positive feedback from both students and lecturers who expressed the need for further digital health education and stated that the field is very important for clinical care and is underrepresented in the current medical curriculum. We extracted a detailed overview of digital health competencies, skills, and knowledge to teach the students from the expert interviews. They also contained suggestions for teaching methods and statements supporting the urgency of the implementation of digital health education in the mandatory curriculum. Conclusions: An elective class seems to be a suitable format for the timely introduction of digital health education. However, a longitudinal implementation in the mandatory curriculum should be the goal. Beyond training future physicians in digital skills and teaching them digital health’s ethical, legal, and social implications, the experience-based development of a critical digital health mindset with openness to innovation and the ability to assess ever-changing health technologies through a broad transdisciplinary approach to translate research into clinical routine seem more important. Therefore, the teaching of digital health should be as practice-based as possible and involve the educational cooperation of different institutions and academic disciplines

Improvements in Patient Monitoring in the Intensive Care Unit: Survey Study

Background: Due to demographic change and, more recently, coronavirus disease (COVID-19), the importance of modern intensive care units (ICU) is becoming apparent. One of the key components of an ICU is the continuous monitoring of patients' vital parameters. However, existing advances in informatics, signal processing, or engineering that could alleviate the burden on ICUs have not yet been applied. This could be due to the lack of user involvement in research and development. Objective: This study focused on the satisfaction of ICU staff with current patient monitoring and their suggestions for future improvements. We aimed to identify aspects of monitoring that interrupt patient care, display devices for remote monitoring, use cases for artificial intelligence (AI), and whether ICU staff members are willing to improve their digital literacy or contribute to the improvement of patient monitoring. We further aimed to identify differences in the responses of different professional groups. Methods: This survey study was performed with ICU staff from 4 ICUs of a German university hospital between November 2019 and January 2020. We developed a web-based 36-item survey questionnaire, by analyzing a preceding qualitative interview study with ICU staff, about the clinical requirements of future patient monitoring. Statistical analyses of questionnaire results included median values with their bootstrapped 95% confidence intervals, and chi-square tests to compare the distributions of item responses of the professional groups. Results: In total, 86 of the 270 ICU physicians and nurses completed the survey questionnaire. The majority stated they felt confident using the patient monitoring equipment, but that high rates of false-positive alarms and the many sensor cables interrupted patient care. Regarding future improvements, respondents asked for wireless sensors, a reduction in the number of false-positive alarms, and hospital standard operating procedures for alarm management. Responses to the display devices proposed for remote patient monitoring were divided. Most respondents indicated it would be useful for earlier alerting or when they were responsible for multiple wards. AI for ICUs would be useful for early detection of complications and an increased risk of mortality; in addition, the AI could propose guidelines for therapy and diagnostics. Transparency, interoperability, usability, and staff training were essential to promote the use of AI. The majority wanted to learn more about new technologies for the ICU and required more time for learning. Physicians had fewer reservations than nurses about AI-based intelligent alarm management and using mobile phones for remote monitoring. Conclusions: This survey study of ICU staff revealed key improvements for patient monitoring in intensive care medicine. Hospital providers and medical device manufacturers should focus on reducing false alarms, implementing hospital alarm standard operating procedures, introducing wireless sensors, preparing for the use of AI, and enhancing the digital literacy of ICU staff. Our results may contribute to the user-centered transfer of digital technologies into practice to alleviate challenges in intensive care medicine. Trial registration: ClinicalTrials.gov NCT03514173; https://clinicaltrials.gov/ct2/show/NCT03514173

Clinical Requirements of Future Patient Monitoring in the Intensive Care Unit: Qualitative Study

BACKGROUND: In the intensive care unit (ICU), continuous patient monitoring is essential to detect critical changes in patients' health statuses and to guide therapy. The implementation of digital health technologies for patient monitoring may further improve patient safety. However, most monitoring devices today are still based on technologies from the 1970s. OBJECTIVE: The aim of this study was to evaluate statements by ICU staff on the current patient monitoring systems and their expectations for future technological developments in order to investigate clinical requirements and barriers to the implementation of future patient monitoring. METHODS: This prospective study was conducted at three intensive care units of a German university hospital. Guideline-based interviews with ICU staff-5 physicians, 6 nurses, and 4 respiratory therapists-were recorded, transcribed, and analyzed using the grounded theory approach. RESULTS: Evaluating the current monitoring system, ICU staff put high emphasis on usability factors such as intuitiveness and visualization. Trend analysis was rarely used; inadequate alarm management as well as the entanglement of monitoring cables were rated as potential patient safety issues. For a future system, the importance of high usability was again emphasized; wireless, noninvasive, and interoperable monitoring sensors were desired; mobile phones for remote patient monitoring and alarm management optimization were needed; and clinical decision support systems based on artificial intelligence were considered useful. Among perceived barriers to implementation of novel technology were lack of trust, fear of losing clinical skills, fear of increasing workload, and lack of awareness of available digital technologies. CONCLUSIONS: This qualitative study on patient monitoring involves core statements from ICU staff. To promote a rapid and sustainable implementation of digital health solutions in the ICU, all health care stakeholders must focus more on user-derived findings. Results on alarm management or mobile devices may be used to prepare ICU staff to use novel technology, to reduce alarm fatigue, to improve medical device usability, and to advance interoperability standards in intensive care medicine. For digital transformation in health care, increasing the trust and awareness of ICU staff in digital health technology may be an essential prerequisite

Perceptions of Digital Health Education Among European Medical Students: Mixed Methods Survey

Background: Digital health technologies hold promise to enhance patient-related outcomes, to support health care staff by reducing their workload, and to improve the coordination of care. As key users of digital health technologies, health care workers are crucial to enable a meaningful digital transformation of health care. Digital health literacy and digital skills should become prerequisite competencies for health professionals to facilitate the implementation and leverage the potential of digital technologies to improve health. Objective: We aimed to assess European medical students' perceived knowledge and opinions toward digital health, the status of digital health implementation in medical education, and the students' most pressing needs. Methods: The explanatory design of our mixed methods study was based on an online, anonymous, self-administered survey targeted toward European medical students. A linear regression analysis was used to identify the influence of the year of medical studies on the responses. Additional analysis was performed by grouping the responses by the self-evaluated frequency of eHealth technology use. Written responses to four qualitative questions in the survey were analyzed using an inductive approach. Results: The survey received a total of 451 responses from 39 European countries, and there were respondents for every year of medical studies. The majority of respondents saw advantages in the use of digital health. While 40.6% (183/451) felt prepared to work in a digitized health care system, more than half (240/451, 53.2%) evaluated their eHealth skills as poor or very poor. Medical students considered lack of education to be the reason for this, with 84.9% (383/451) agreeing or strongly agreeing that more digital health education should be implemented in the medical curriculum. Students demanded introductory and specific eHealth courses covering data management, ethical aspects, legal frameworks, research and entrepreneurial opportunities, role in public health and health systems, communication skills, and practical training. The emphasis lay on tailoring learning to future job requirements and interprofessional education. Conclusions: This study shows a lack of digital health-related formats in medical education and a perceived lack of digital health literacy among European medical students. Our findings indicate a gap between the willingness of medical students to take an active role by becoming key players in the digital transformation of health care and the education that they receive through their faculties

Creation of an Evidence-Based Implementation Framework for Digital Health Technology in the Intensive Care Unit: Qualitative Study

Background: Digital health technologies such as continuous remote monitoring and artificial intelligence–driven clinical decision support systems could improve clinical outcomes in intensive care medicine. However, comprehensive evidence and guidelines for the successful implementation of digital health technologies into specific clinical settings such as the intensive care unit (ICU) are scarce. We evaluated the implementation of a remote patient monitoring platform and derived a framework proposal for the implementation of digital health technology in an ICU. Objective: This study aims to investigate barriers and facilitators to the implementation of a remote patient monitoring technology and to develop a proposal for an implementation framework for digital health technology in the ICU. Methods: This study was conducted from May 2018 to March 2020 during the implementation of a tablet computer–based remote patient monitoring system. The system was installed in the ICU of a large German university hospital as a supplementary monitoring device. Following a hybrid qualitative approach with inductive and deductive elements, we used the Consolidated Framework for Implementation Research and the Expert Recommendations for Implementing Change to analyze the transcripts of 7 semistructured interviews with clinical ICU stakeholders and descriptive questionnaire data. The results of the qualitative analysis, together with the findings from informal meetings, field observations, and previous explorations, provided the basis for the derivation of the proposed framework. Results: This study revealed an insufficient implementation process due to lack of staff engagement and few perceived benefits from the novel solution. Further implementation barriers were the high staff presence and monitoring coverage in the ICU. The implementation framework includes strategies to be applied before and during implementation, targeting the implementation setting by involving all ICU stakeholders, assessing the intervention’s adaptability, facilitating the implementation process, and maintaining a vital feedback culture. Setting up a unit responsible for implementation, considering the guidance of an implementation advisor, and building on existing institutional capacities could improve the institutional context of implementation projects in the ICU. Conclusions: Implementation of digital health in the ICU should involve a thorough preimplementation assessment of the ICU’s need for innovation and its readiness to change, as well as an ongoing evaluation of the implementation conditions. Involvement of all stakeholders, transparent communication, and continuous feedback in an equal atmosphere are essential, but leadership roles must be clearly defined and competently filled. Our proposed framework may guide health care providers with concrete, evidence-based, and step-by-step recommendations for implementation practice, facilitating the introduction of digital health in intensive care. Trial Registration: ClinicalTrials.gov NCT03514173; https://clinicaltrials.gov/ct2/show/NCT0351417

A Remote Patient-Monitoring System for Intensive Care Medicine: Mixed Methods Human-Centered Design and Usability Evaluation

Background: Continuous monitoring of vital signs is critical for ensuring patient safety in intensive care units (ICUs) and is becoming increasingly relevant in general wards. The effectiveness of health information technologies such as patient-monitoring systems is highly determined by usability, the lack of which can ultimately compromise patient safety. Usability problems can be identified and prevented by involving users (ie, clinicians). Objective: In this study, we aim to apply a human-centered design approach to evaluate the usability of a remote patient-monitoring system user interface (UI) in the ICU context and conceptualize and evaluate design changes. Methods: Following institutional review board approval (EA1/031/18), a formative evaluation of the monitoring UI was performed. Simulated use tests with think-aloud protocols were conducted with ICU staff (n=5), and the resulting qualitative data were analyzed using a deductive analytic approach. On the basis of the identified usability problems, we conceptualized informed design changes and applied them to develop an improved prototype of the monitoring UI. Comparing the UIs, we evaluated perceived usability using the System Usability Scale, performance efficiency with the normative path deviation, and effectiveness by measuring the task completion rate (n=5). Measures were tested for statistical significance using a 2-sample t test, Poisson regression with a generalized linear mixed-effects model, and the N-1 chi-square test. P<.05 were considered significant. Results: We found 37 individual usability problems specific to monitoring UI, which could be assigned to six subcodes: usefulness of the system, response time, responsiveness, meaning of labels, function of UI elements, and navigation. Among user ideas and requirements for the UI were high usability, customizability, and the provision of audible alarm notifications. Changes in graphics and design were proposed to allow for better navigation, information retrieval, and spatial orientation. The UI was revised by creating a prototype with a more responsive design and changes regarding labeling and UI elements. Statistical analysis showed that perceived usability improved significantly (System Usability Scale design A: mean 68.5, SD 11.26, n=5; design B: mean 89, SD 4.87, n=5; P=.003), as did performance efficiency (normative path deviation design A: mean 8.8, SD 5.26, n=5; design B: mean 3.2, SD 3.03, n=5; P=.001), and effectiveness (design A: 18 trials, failed 7, 39% times, passed 11, 61% times; design B: 20 trials, failed 0 times, passed 20 times; P=.002). Conclusions: Usability testing with think-aloud protocols led to a patient-monitoring UI with significantly improved usability, performance, and effectiveness. In the ICU work environment, difficult-to-use technology may result in detrimental outcomes for staff and patients. Technical devices should be designed to support efficient and effective work processes. Our results suggest that this can be achieved by applying basic human-centered design methods and principles. Trial Registration: ClinicalTrials.gov NCT03514173; https://clinicaltrials.gov/ct2/show/NCT0351417

The medical profession transformed by artificial intelligence: Qualitative study

Background Healthcaare delivery will change through the increasing use of artificial intelligence (AI). Physicians are likely to be among the professions most affected, though to what extent is not yet clear. Objective We analyzed physicians’ and AI experts’ stances towards AI-induced changes. This concerned (1) physicians’ tasks, (2) job replacement risk, and (3) implications for the ways of working, including human–AI interaction, changes in job profiles, and hierarchical and cross-professional collaboration patterns. Methods We adopted an exploratory, qualitative research approach, using semi-structured interviews with 24 experts in the fields of AI and medicine, medical informatics, digital medicine, and medical education and training. Thematic analysis of the interview transcripts was performed. Results Specialized tasks currently performed by physicians in all areas of medicine would likely be taken over by AI, including bureaucratic tasks, clinical decision support, and research. However, the concern that physicians will be replaced by an AI system is unfounded, according to experts; AI systems today would be designed only for a specific use case and could not replace the human factor in the patient–physician relationship. Nevertheless, the job profile and professional role of physicians would be transformed as a result of new forms of human–AI collaboration and shifts to higher-value activities. AI could spur novel, more interprofessional teams in medical practice and research and, eventually, democratization and de-hierarchization. Conclusions The study highlights changes in job profiles of physicians and outlines demands for new categories of medical professionals considering AI-induced changes of work. Physicians should redefine their self-image and assume more responsibility in the age of AI-supported medicine. There is a need for the development of scenarios and concepts for future job profiles in the health professions as well as their education and training

Staff perspectives on the influence of patient characteristics on alarm management in the intensive care unit: a cross-sectional survey study

Abstract Background High rates of clinical alarms in the intensive care unit can result in alarm fatigue among staff. Individualization of alarm thresholds is regarded as one measure to reduce non-actionable alarms. The aim of this study was to investigate staff’s perceptions of alarm threshold individualization according to patient characteristics and disease status. Methods This is a cross-sectional survey study (February-July 2020). Intensive care nurses and physicians were sampled by convenience. Data was collected using an online questionnaire. Results Staff view the individualization of alarm thresholds in the monitoring of vital signs as important. The extent to which alarm thresholds are adapted from the normal range varies depending on the vital sign monitored, the reason for clinical deterioration, and the professional group asked. Vital signs used for hemodynamic monitoring (heart rate and blood pressure) were most subject to alarm individualizations. Staff are ambivalent regarding the integration of novel technological features into alarm management. Conclusions All relevant stakeholders, including clinicians, hospital management, and industry, must collaborate to establish a “standard for individualization,” moving away from ad hoc alarm management to an intelligent, data-driven alarm management. Making alarms meaningful and trustworthy again has the potential to mitigate alarm fatigue – a major cause of stress in clinical staff and considerable hazard to patient safety. Trial registration The study was registered at ClinicalTrials.gov (NCT03514173) on 02/05/2018