Results demonstrate the feasibility of using an online clinical tool to enable PCPs to promote physical activity in high-risk patients. The developed clinical interface is a promising approach to help reorient primary care providers on lifestyle factors such as physical activity promotion [33
]. The PCMH concept of care combines information technology tools with a collaborative team approach to provide more time for services like physical activity counseling. Programs like SUH help support the PCMH concept of care by emphasizing the efficient application of information technology to facilitate coordination between patients and their providers [24
]. SUH supports patients with personalized walking goals and feedback, facilitates ongoing patient-provider communication, and gives PCPs the ability to prospectively monitor patient progress and safety.
The SUH intervention and clinical interface have several advantages over previous strategies used to promote lifestyle change in primary care. One advantage is that the automated referral process requires minimal provider time and can reach large numbers of patients with a consistent approach [36
] in contrast to more traditional strategies such as face-to-face provider counseling [37
] or referral by clinical staff to community programs [33
]. A second advantage is that the clinical interface gives clinical providers ongoing feedback and monitoring regarding the progress of patients' walking programs. This second strength is further enhanced by the capability of patients and providers to email each other as needed so that the intervention is not disconnected from clinical practice after referral [41
]. This is consistent with the PCMH model of care in that the primary health care team remains informed about all aspects of care.
The clinical interface provided PCPs with the option of either directly referring patients to SUH during a clinical encounter or using a clinical database to identify eligible patients to send a referral letter by mail. Over 25% of the patients referred to SUH were enrolled despite some providers expressing lack of confidence in their physical activity counseling skill. This lack of confidence is a known barrier to successful implementation of practice-based physical activity interventions [43
]. It is possible that training programs for providers that directly address physical activity counseling skills may increase program adoption by patients. Nonetheless, use of a physical activity program by 25% of a practice network's high-risk patients could yield a significant population effect on morbidity and mortality, service utilization, and patient quality of life and optimal function.
Although providers were successful in referring patients to the program, they rarely used the clinical interface to monitor patients enrolled in SUH. This may have been due to the short duration of the follow-up period, lack of time for providers, and lack of integration of the clinical interface into the clinics' EMR infrastructure. Prior studies of automated clinical tools to support behavior change have noted that full integration of these tools with the practice EMR is desirable but challenging. Integration allows efficient access information for patient monitoring and consultation [45
Implementation of SUH could be improved by emphasizing a team-based approach to patient referral and by ongoing program monitoring. Involving MAs more regularly in participant monitoring might have strengthened the effect on patient adoption and use of SUH. Time constraints faced by physician providers necessitate greater reliance on nurses and MAs [24
]. Furthermore, evidence suggests health behavioral change interventions are more effective when allied health personnel are trained to augment physician brief counseling and education efforts [46
While the focus of this study was on testing the feasibility of the SUH as a clinical practice tool [50
], Phase II testing revealed encouraging preliminary patient outcome results. Referred patients who chose to participate in the walking program significantly increased their physical activity over six weeks from an average of 45 min/wk to 72 min/wk. Despite the automated nature of the SUH walking program, participants reported high levels of satisfaction with the program. As demonstrated in previous walking studies, high-risk patients were able to successfully participate without experiencing serious adverse events [51
This study used a combination of evaluation methods suited to assessing the feasibility of implementing an intervention in real world settings [52
]. First, this study employed an iterative, user-centered design process to ensure that the clinical interface met the needs of the providers [28
]. Multiple qualitative interviews with providers identified user needs and barriers to implementation that could not be easily understood using quantitative data alone [29
]. Second, we recognized the competing priorities and time limitations faced by providers during clinical encounters and automated the SUH referral processes to minimize PCP burden. Finally, to focus on implementation rather than efficacy, there was minimal contact between researchers and provider teams or patients during Phase II testing. Thus, provider pairs tested the system in the context of their regular clinical workflow.
There are several study limitations worth noting. First, the study did not utilize a randomised controlled trial design with comparison to standard-of-care control participants. As previously noted, the developmental costs of many e-health technological interventions necessitate the use of smaller pilot studies as part of iterative research in preparation of a randomised, controlled comparative effectiveness trial (RCT). An RCT establishes clinical efficacy and cost-effectiveness in defined patient groups, but this approach was beyond the scope and aims of the current study. Notably, the current study enabled the development of a robust provider interface that lays the groundwork for SUH to be comparatively evaluated in a future RCT. Second, the short duration of this pilot intervention did not reflect real world practice where patients would be monitored over months or years versus 6-7 weeks. The short duration of the intervention may have limited provider motivation to monitor participant progress. However, the primary emphasis of this pilot study was to develop a robust clinical interface and to establish feasibility with a small sample of end users (e.g., clinical staff and patients). Third, it is also worth noting that the study did not assess changes in physiological outcomes and did not assess practical screening measures to facilitate referral to SUH. Physiological outcomes such as changes in blood pressure, cholesterol or blood glucose are key indicators of self-management outcomes. However, outcomes in this study focused on indicators of satisfaction and program engagement by the end users.
In the present study, provider pairs were engaged in the interface design process during Phase I and reviewed proposed interface implementation strategies. The providers had fewer opportunities to provide input into workflow integration issues once the interface was developed. This is a significant and fourth limitation as workflow concerns and, in particular, concerns about increased workload were frequently mentioned by providers. PCMH efforts to reorganize processes of care and improve productivity through technological innovations may have unintended consequences by actually creating additional work or causing provider dissatisfaction particularly if providers do not have the opportunity to influence practice redesign efforts [54
Results from this study provide a foundation to build on in future investigations. In particular, more work is needed to ensure that the interface is flexible enough to accommodate a broad range of variation in workflow patterns and to ensure intervention protocols are acceptable and feasible to providers.
As a fifth limitation, providers also complained that SUH was not part of the clinical EMR. Ideally, research intervention programs like SUH could be tested as part of the EMR and embedded with all patient medical information. This association could allow rapid comparison of program progress with changes in physiological outcomes (e.g. hemoglobin A1c, lipids). In addition, electronic patient visit prompts could remind providers to inquire about program walking progress. Finally, this study sample was a small group of volunteer patients from only two family medicine clinics, which limits generalization and the statistical power of our analyses to examine the influence of factors such as patient characteristics (e.g. prior pedometer use) on the results.