A New Mobile-responsive Solution to Increase Patient Adherence: Instant Personalized Product Handouts

Objective. This study aims to develop a solution for clinicians to quickly generate customized product handouts with clinical, coverage, pricing, and supplier information for patients, with the goal of increasing patient adherence. Methods. Using design thinking methodology, a digital solution was developed as a module within a clinical/reimbursement decision-support web application for wound care and hyperbaric clinicians. The module was tested at 4 wound clinics (beta-sites) located in the Midwest region of the United States following a 1-group posttest study design. Results. Ten clinicians at the 4 beta-sites completed a survey upon evaluation. All respondents indicated they would use the module daily or weekly. Most users (80%) indicated it met their needs very well (vs. moderately or not as much). Nurses who shared handouts with patients found 7 of 8 handouts were useful or very useful in increasing patient adherence to the plan of care. Conclusions. A digital point-of-care solution that generates customized product handouts with clinical, coverage, pricing, and supplier information may significantly improve patient adherence while saving clinicians time.

Adherence to a treatment plan depends on complex interactions between patients, caregivers, clinicians, and industry.¹ Nonadherence to treatment plans among patients with chronic wounds (reported to be about 50%) remains a major issue.^2,3 Insufficient knowledge of their conditions and treatments hampers patients’ abilities to partner with clinicians regarding their own care and has been cited as a major reason for nonadherence.^1,4,5 

To follow their wound treatment plan, patients need to know how to appropriately use wound care products, where to obtain them, and how much they cost.⁶ Clinicians are responsible for gathering this information and supplying appropriate education so that patients understand and fulfill their roles in treatment.⁶ However, clinicians’ busy schedules and the lack of easily obtainable information are frequent obstacles to meeting these needs. 

This study aimed to develop a solution for clinicians to quickly generate customized product handouts with clinical, coverage, pricing, and supplier information for patients, with the goal of increasing patient adherence.

Module 
Using design thinking (DT) methodology,⁷ a process for creative problem solving, a digital solution was developed as a module within a clinical and reimbursement decision-support web application for wound care and hyperbaric clinicians (WoundReference Clinical Decision Support Web App; Wound Reference, Inc, San Francisco, CA). This application is an online platform comprised of evidence-based modules to support decision making at the point-of-care. 
 

Study design
The DT methodology was utilized in this study. Evaluations of the module were conducted following a 1-group posttest study design. The DT methodology is comprised of 4 phases: discover, define, develop, and deliver. 

Discover. Literature review was performed. In-person or phone interviews were conducted with a convenience sample of 10 wound care clinicians from different regions of the United States. The clinicians were asked to identify challenges in patient adherence and product procurement.

Define. Findings collected in the Discover phase were analyzed and specific problems were identified.

Develop. The clinicians, digital user experience specialist, designer, and programmer brainstormed on potential solutions for problems previously identified, and the first functional module was created.

Evaluation. Two rounds of evaluation were completed following a 1-group posttest study design. After each evaluation, users’ feedback was incorporated into the subsequent version of the module.
 

First round
In the first round of evaluation, the initial version of the module was beta-tested at 4 wound clinics in the Midwest region of the United States (beta-sites). 

Ten nurses and nurse practitioners with 5 to 15 years of experience in wound care working at the 4 beta-sites were invited to participate (2–3 clinicians per site). These 10 beta-site clinicians were asked to evaluate the product handout module and choose 1 answer for each of the 2 questions: 

• How often would you use the product handout module? (3: daily, 2: weekly, 1: monthly) 
• How well does it meet your needs? (3: very well, 2: moderately well, 1: not as much)

Upon collection of the survey results, subjective assessment on the module and suggestions for improvement were provided by the beta-site clinicians over the phone or in person. Feedback was incorporated into the module prior to the second round of evaluation.
 

Second round
In the second round of evaluation, 2 nurses among the 10 beta-site clinicians were invited to incorporate the module into their clinical workflow and share customized handouts with 8 different patients. Upon the next follow-up visit, patients and nurses responded to the following survey questions: 

Questions for nurses:

• How useful/not useful was the handout in increasing patient adherence to the plan of care? (5-points scale; 5: very useful, 1: not useful at all) 
• Any suggestions for improvement of this specific product handout given to the patient?

Questions for patients:

• Overall, how helpful/not helpful do you think the handout was? (5-point scale; 5: very helpful, 1: not helpful at all)
• How helpful/not helpful do you think each of the specific sections of the handout was? (5-point scale; 5: very helpful, 1: not helpful at all) 
  • Product description
  • Medicare coverage and copayment
  • Medicare suppliers and pricing

Deliver
Feedback from beta-sites was incorporated into the final version of the module.

Discover and define
Literature search was conducted on PubMed and Google Scholar. Search terms used in this study included: patient adherence, patient compliance, wound care, chronic wound, product, procurement, and nonhealing wounds. Inclusion criteria were publication date between 2013 and 2018 and description on challenges or solutions in patient adherence, with a special emphasis on product procurement. Exclusion criteria included non-English language articles, and on Google Scholar, articles listed after the tenth page or ranked higher than one-hundredth in order of appearance due to low probability of relevance. A search of the aforementioned databases yielded more than 180 articles when patient adherence or patient compliance was matched with wound care or chronic wound or product or supply and procurement. After review of all study titles, 16 abstracts were selected for analysis. A total of 9 abstracts were relevant to this study, and these articles underwent final review in their entirety. Of these, 6 were included in the Discover phase.

Through literature review and interviews with 10 wound care clinicians, the following specific problems were identified: 

• Clinicians in the outpatient setting are busy and unbiased wound care product information for patients is scarce or scattered.
• For routinely prescribed items, patients are frequently asked to contact preferred durable medical equipment (DME) suppliers. Only then, patients may or may not receive information on how to use a product, insurance coverage, and pricing. At this point, patients may have questions and concerns that, if not addressed promptly, contribute to nonadherence.
• For non-routine items (eg, support surfaces, offloading devices), clinicians often spend valuable time obtaining information on suppliers, insurance coverage, and pricing.

Develop 
Based on these specific problems, potential solutions were created and tested. Initial wireframes were evaluated by clinicians, and based on their suggestions, the first functional module was created with robust programming language and framework (Microsoft, Redmond, WA), a library (JavaScript), and application programming interfaces (eg, CMS, Baltimore, MD). The initial version of the product handout module allowed clinicians to instantly generate customized handouts by choosing a product, entering the patient’s ZIP code, and selecting a desired type of information, including product description, local DMEs, online stores, out-of-pocket pricing, and Medicare coverage/copayment (Figure 1).

Evaluation
This initial version of the module was evaluated by 10 clinicians at 4 beta-sites who completed a survey upon evaluation. All respondents indicated they would use the module daily or weekly. Most users (80%; 8/10) indicated that it meets their needs very well (vs. moderately or not as much). As for desired features, users requested an option to add recommended DMEs and customized notes.

Desired features were added (Figure 2), and for the second evaluation, 2 wound care nurses among the 10 beta-site clinicians incorporated the module into their clinical workflow and shared customized handouts with 8 patients. Clinicians and patients completed a survey upon follow-up visit. Overall, patients found the handout to be helpful or very helpful, with the average score being 4.1 (where 1 was not helpful and 5 was very helpful). The average score from the patients for specific areas of the handout are shown in Figure 3. 

The 2 nurses found 7 of 8 patient handouts shared with the 8 patients were useful or very useful in increasing patient adherence to the plan of care. The average score of the 8 handouts from the nurses’ perspective was 4 (with 1 being not useful at all and 5 being very useful). Based on clinicians’ and patients’ feedback, an option was added to separately hide or display Medicare suppliers and copayment information.

Deliver
The current module was built based on the process and feedback previously described. It is accessible across multiple devices (eg, desktop, mobile) and allows clinicians to generate more than 1000 different types of wound care product handouts with information extracted from the decision-support application database. Handouts can be printed at the point-of-care or sent via email to patients and caregivers. Frequently used handouts can be saved as favorites. 

Practical resources that enable clinicians to instantly gather information needed for patient education and product procurement in a customized manner are scarce or nonexistent. This newly developed module provides an option to meet this need as it conveniently generates customized product handouts with clinical, coverage, pricing, and supplier information. Clinicians can check upfront if a product meets insurance and/or formulary requirements and choose an alternative if needed. Providers can develop wound care plans in a format that patients can follow, which increases chances of adherence.

This evaluation is limited by its pre- experimental design and small number of participants. Future studies that utilize randomization and a control group will enable a clearer assessment of the impact of the module on patient adherence. Nevertheless, the DT methodology employed herein ensured that development of the product was patient- and clinician-driven, as opposed to a product based on developers’ assumptions.  

A digital, point-of-care solution that generates customized product handouts with clinical, coverage, pricing, and supplier information was developed and may improve patient adherence significantly while saving clinicians time.

Authors: Elaine Horibe Song, MD, PhD, MBA¹; Catherine T. Milne, APRN, MSN, CWOCN-AP²; Tiffany Hamm, BSN, RN, ACHRN, CWS¹; Jeffrey Mize, RRT, CHT, CWCA¹; Nataliya Lebendiskaya, RN, BSN, CWOCN³; Scott Robinson, MD⁴; Erin Ensz, RN, BSN⁴; Dee Anne Schoenfeld, RN, BSN⁴; Kathryn Whiston-Lemm, ACNP, CWON⁵; Alex K. Wong, MD, FACS⁶; and Lydia Ferreira, MD, PhD, MBA⁷

Affiliations: ¹Wound Reference, Inc, San Francisco, CA; ²Connecticut Clinical Nursing Associates, Bristol, CT; ³Kaiser Performanente, Oakland, CA; ⁴Lawrence Memorial Hospital, Lawrence, KS; ⁵Queen of the Valley Medical Center, Napa, CA; ⁶University of Southern California, Los Angeles, CA; and ⁷Federal University of São Paulo, São Paulo, Brazil

Correspondence: Elaine Horibe Song, MD, PhD, MBA, CEO, Wound Reference, Inc, 1662 Chestnut Street, San Francisco, CA 94213; esong@woundreference.com

Disclosure: Data were presented as a poster at the 2018 Symposium on Advanced Wound Care Fall in Las Vegas, NV. Dr. Song, Ms. Hamm, and Mr. Mize are employees of Wound Reference, Inc. All other authors disclose no financial or other conflicts of interest.