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Building Virtual Health Training Tools for Residents: A Design Thinking Approach

Lawrence, Katharine; Cho, James; Torres, Christian; Alfaro-Arias, Veronica
The COVID-19 pandemic drove a rapid transition to virtual care experiences for graduate medical trainees. Core training competencies have expanded to incorporate virtual contexts, however there is limited knowledge of the optimal design of virtual care training tools for learners. In this study, we describe the application of a Design Thinking approach to the identification and co-design of novel training tools to support residents and precepting attending physicians in virtual ambulatory care practice. We applied the model of "Empathize, Define, Ideate, Prototype, and Test" via a mixed methods approach to (1) explore the needs, preferences, and concerns of Internal Medicine residents and outpatient precepting attendings regarding virtual ambulatory care training environments, and (2) evaluate, prototype, and test potential training tools. Eleven residents and eight attending physicians participated. Identified learner needs and problem areas included: improving virtual visit technical skills; acquiring virtual communication skills; adapting to the loss of shared in-person learning space and optimizing virtual learning environments; remediating non-virtual procedural competencies; and educating on new documentation requirements. Key solution areas included: virtual precepting support tools; digital information and education dissemination tools; and strategies for management of technical issues. Several prototypes were proposed, with a single tool (a virtual preceptor tip sheet) deployed in clinical practice. Residents found the workshop program improved their understanding of Design Thinking and its relevance to healthcare. Ultimately, Design Thinking can be deployed to engage medical trainees and precepting attendings in the effective development of novel educational tools for the virtual care learning environment.
PMCID:9234169
PMID: 35770138
ISSN: 2673-253x
CID: 5281252

A user-centered design approach to building telemedicine training tools for residents [Meeting Abstract]

Lawrence, K; Cho, J; Torres, C; Arias, V A
STATEMENT OF PROBLEM OR QUESTION (ONE SENTENCE): Can user-centered design (UCD) facilitate the development of novel and effective training tools for the virtual ambulatory learning environment LEARNING OBJECTIVES 1: To identify the needs, preferences, and concerns of resident trainees and attending preceptors regarding the current virtual ambulatory care learning environment. LEARNING OBJECTIVES 2: To apply user-centered design (UCD) strategies to the development of effective tools to enhance the virtual learning experience of trainees and preceptors. DESCRIPTION OF PROGRAM/INTERVENTION, INCLUDING ORGANIZATIONAL CONTEXT (E.G. INPATIENT VS. OUTPATIENT, PRACTICE OR COMMUNITY CHARACTERISTICS): The COVID-19 pandemic spurred a rapid transition to virtual learning environments, the design of which may impact learning experiences and competency development for trainees. User-centered design (UCD) offers a framework to iteratively and collaboratively incorporate needs, preferences, and concerns of users (e.g. trainees and preceptors) in the development of acceptable and effective educational tools. This study applied UCD strategies of empathize, define, ideate, prototype, and test among Internal Medicine residents and outpatient attending preceptors to develop innovations for the virtual ambulatory care learning environment. MEASURES OF SUCCESS (DISCUSS QUALITATIVE AND/OR QUANTITATIVEMETRICSWHICHWILL BEUSEDTOEVALUATE PROGRAM/INTERVENTION): Using the UCD framework, we identified: 1) needs, preferences, and concerns of residents and preceptors in current virtual precepting practices (empathize) 2) key problem areas and pain points (define) 3) potential solutions (ideate) 4) specific products to develop (prototype), deploy, and evaluate (test) in practice FINDINGS TO DATE (IT IS NOT SUFFICIENT TO STATE FINDINGS WILL BE DISCUSSED): Qualitative needs-assessment interviews were conducted among 8 residents and 10 preceptors, which identified key areas of learner need: technical and workflow competency; the virtual precepting experience; patient rapport-building and communication; and documentation requirements. Subsequently, a Design Thinking Workshop focusing on virtual precepting was developed, and 3 workshops were conducted with 12 participants (residents and attendings). Using a three-phase interactive sequence of explore, ideate, and create, participants were divided into 2-or 3-person virtual breakout groups and asked to 1) identify a key problem in current virtual precepting, 2) brainstorm possible solutions, and 3) design and present a low-fidelity prototype of one solution. Key problems identified included: management of technical issues, goal setting for precepting sessions, clinic-specific information dissemination practices, and the loss of shared learning space with colleagues. Potential solutions included: a digital shared-learning plan for residents, a real-time virtual clinical bulletin board, an integrated virtual team huddle, and just-in-time digital chalk talks. Two prototypes are being developed for testing in the live precepting environment. KEY LESSONS FOR DISSEMINATION (WHAT CAN OTHERS TAKE AWAY FOR IMPLEMENTATION TO THEIR PRACTICE OR COMMUNITY): User-centered design can be deployed as an effective strategy to engage learners and preceptors in the design and development of educational innovations for the virtual training environment. We recommend collaborating with residents, preceptors, and other stakeholders in the iterative design of virtual learning tools
EMBASE:635797162
ISSN: 1525-1497
CID: 4986532

Addendum to: The Mobile Insulin Titration Intervention (MITI) for Insulin Glargine Titration in an Urban, Low-Income Population: Randomized Controlled Trial Protocol

Levy, Natalie; Moynihan, Victoria; Nilo, Annielyn; Singer, Karyn; Bernik, Lidia S; Etiebet, Mary-Ann; Fang, Yixin; Cho, James; Natarajan, Sundar
PMID: 30578192
ISSN: 1929-0748
CID: 3560022

The Mobile Insulin Titration Intervention (MITI) for Insulin Adjustment in an Urban, Low-Income Population: Randomized Controlled Trial

Levy, Natalie; Moynihan, Victoria; Nilo, Annielyn; Singer, Karyn; Bernik, Lidia S; Etiebet, Mary-Ann; Fang, Yixin; Cho, James; Natarajan, Sundar
BACKGROUND: Diabetes patients are usually started on a low dose of insulin and their dose is adjusted or "titrated" according to their blood glucose levels. Insulin titration administered through face-to-face visits with a clinician can be time consuming and logistically burdensome for patients, especially those of low socioeconomic status (SES). Given the wide use of mobile phones among this population, there is the potential to use short message service (SMS) text messaging and phone calls to perform insulin titration remotely. OBJECTIVE: The goals of this pilot study were to (1) evaluate if our Mobile Insulin Titration Intervention (MITI) intervention using text messaging and phone calls was effective in helping patients reach their optimal insulin glargine dose within 12 weeks, (2) assess the feasibility of the intervention within our clinic setting and patient population, (3) collect data on the cost savings associated with the intervention, and (4) measure patient satisfaction with the intervention. METHODS: This was a pilot study evaluating an intervention for patients requiring insulin glargine titration in the outpatient medical clinic of Bellevue Hospital Center in New York City. Patients in the intervention arm received weekday SMS text messages from a health management platform requesting their fasting blood glucose values. The clinic's diabetes nurse educator monitored the texted responses on the platform website each weekday for alarm values. Once a week, the nurse reviewed the glucose values, consulted the MITI titration algorithm, and called patients to adjust their insulin dose. Patients in the usual care arm continued to receive their standard clinic care for insulin titration. The primary outcome was whether a patient reached his/her optimal insulin glargine dose within 12 weeks. RESULTS: A total of 61 patients consented and were randomized into the study. A significantly greater proportion of patients in the intervention arm reached their optimal insulin glargine dose than patients in the usual care arm (88%, 29/33 vs 37%, 10/27; P<.001). Patients responded to 84.3% (420/498) of the SMS text messages requesting their blood glucose values. The nurse reached patients within 2 attempts or by voicemail 91% of the time (90/99 assigned calls). When patients traveled to the clinic, they spent a median of 45 minutes (IQR 30-60) on travel and 39 minutes (IQR 30-64) waiting prior to appointments. A total of 61% (37/61) of patients had appointment copays. After participating in the study, patients in the intervention arm reported higher treatment satisfaction than those in the usual care arm. CONCLUSIONS: MITI is an effective way to help low-SES patients reach their optimal insulin glargine dose using basic SMS text messaging and phone calls. The intervention was feasible and patients were highly satisfied with their treatment. The intervention was cost saving in terms of time for patients, who were able to have their insulin titrated without multiple clinic appointments. Similar interventions should be explored to improve care for low-SES patients managing chronic disease. TRIAL REGISTRATION: Clinicaltrials.gov NCT01879579; https://clinicaltrials.gov/ct2/show/NCT01879579 (Archived by WebCite at http://www.webcitation.org/6YZik33L3).
PMCID:4527003
PMID: 26187303
ISSN: 1438-8871
CID: 1669122

THE MOBILE INSULIN TITRATION INTERVENTION (MITI) STUDY: INNOVATIVE CHRONIC DISEASE MANAGEMENT OF DIABETES [Meeting Abstract]

Levy, Natalie K; Moynihan, Victoria; Nilo, Annielyn; Singer, Karyn; Etiebet, Mary-Ann; Bernik, Lidia; Cho, James H; Fang, Yixin; Natarajan, Sundar
ISI:000358386902237
ISSN: 1525-1497
CID: 1730222

The Mobile Insulin Titration Intervention (MITI) for Insulin Glargine Titration in an Urban, Low-Income Population: Randomized Controlled Trial Protocol

Levy, Natalie; Moynihan, Victoria; Nilo, Annielyn; Singer, Karyn; Bernik, Lidia S; Etiebet, Mary-Ann; Fang, Yixin; Cho, James; Natarajan, Sundar
BACKGROUND: Patients on insulin glargine typically visit a clinician to obtain advice on how to adjust their insulin dose. These multiple clinic visits can be costly and time-consuming, particularly for low-income patients. It may be feasible to achieve insulin titration through text messages and phone calls with patients instead of face-to-face clinic visits. OBJECTIVE: The objectives of this study are to (1) evaluate if the Mobile Insulin Titration Intervention (MITI) is clinically effective by helping patients reach their optimal dose of insulin glargine, (2) determine if the intervention is feasible within the setting and population, (3) assess patient satisfaction with the intervention, and (4) measure the costs associated with this intervention. METHODS: This is a pilot study evaluating an approach to insulin titration using text messages and phone calls among patients with insulin-dependent type 2 diabetes in the outpatient medical clinic of Bellevue Hospital Center, a safety-net hospital in New York City. Patients will be randomized in a 1:1 ratio to either the MITI arm (texting/phone call intervention) or the usual-care arm (in-person clinic visits). Using a Web-based platform, weekday text messages will be sent to patients in the MITI arm, asking them to text back their fasting blood glucose values. In addition to daily reviews for alarm values, a clinician will rereview the texted values weekly, consult our physician-approved titration algorithm, and call the patients with advice on how to adjust their insulin dose. The primary outcome will be whether or not a patient reaches his/her optimal dose of insulin glargine within 12 weeks. RESULTS: Recruitment for this study occurred between June 2013 and December 2014. We are continuing to collect intervention and follow-up data from our patients who are currently enrolled. The results of our data analysis are expected to be available in 2015. CONCLUSIONS: This study explores the use of widely-available text messaging and voice technologies for insulin titration. We aim to show that remote insulin titration is clinically effective, feasible, satisfactory, and cost saving for low-income patients in a busy, urban clinic. TRIAL REGISTRATION: Clinicaltrials.gov NCT01879579; http://clinicaltrials.gov/ct2/show/NCT01879579 (Archived by WebCite at http://www.webcitation.org/6WUEgjZUO).
PMCID:4381814
PMID: 25794243
ISSN: 1929-0748
CID: 1531922