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1.  ClereMed: Lessons Learned From a Pilot Study of a Mobile Screening Tool to Identify and Support Adults Who Have Difficulty With Medication Labels 
JMIR mHealth and uHealth  2014;2(3):e35.
In order to take medications safely and effectively, individuals need to be able to see, read, and understand the medication labels. However, one-half of medication labels are currently misunderstood, often because of low literacy, low vision, and cognitive impairment. We sought to design a mobile tool termed ClereMed that could rapidly screen for adults who have difficulty reading or understanding their medication labels.
The aim of this study was to build the ClereMed prototype; to determine the usability of the prototype with adults 55 and over; to assess its accuracy for identifying adults with low-functional reading ability, poor ability on a real-life pill-sorting task, and low cognition; and to assess the acceptability of a touchscreen device with older adults with age-related changes to vision and cognition.
This pilot study enrolled adults (≥55 years) who were recruited through pharmacies, retirement residences, and a low-vision optometry clinic. ClereMed is a hypertext markup language (HTML)-5 prototype app that simulates medication taking using an iPad, and also provides information on how to improve the accessibility of prescription labels. A paper-based questionnaire included questions on participant demographics, computer literacy, and the Systems Usability Scale (SUS). Cognition was assessed using the Montreal Cognitive Assessment tool, and functional reading ability was measured using the MNRead Acuity Chart. Simulation results were compared with a real-life, medication-taking exercise using prescription vials, tablets, and pillboxes.
The 47 participants had a mean age of 76 (SD 11) years and 60% (28/47) were female. Of the participants, 32% (15/47) did not own a computer or touchscreen device. The mean SUS score was 76/100. ClereMed correctly identified 72% (5/7) of participants with functional reading difficulty, and 63% (5/8) who failed a real-life pill-sorting task, but only 21% (6/28) of participants with cognitive impairment. Participants who owned a computer or touchscreen completed ClereMed in a mean time of 26 (SD 16) seconds, compared with 52 (SD 34) seconds for those who do not own a device (P<.001). Those who had difficulty, struggled with screen glare, button activation, and the “drag and drop” function.
ClereMed was well accepted by older participants, but it was only moderately accurate for reading ability and not for mild cognitive impairment. Future versions may be most useful as part of a larger medication assessment or as a tool to help family members and caregivers identify individuals with impaired functional reading ability. Future research is needed to improve the sensitivity for measuring cognitive impairment and on the feasibility of implementing a mobile app into pharmacy workflow.
PMCID: PMC4147709  PMID: 25131813
low vision; legibility; prescription labelling; medication labels; usability; cognitive impairment; visual impairment
2.  Telephone interviews vs. workstation sessions for acquiring quality of life data. 
Patient quality of life data can be acquired in a variety of ways, including over the telephone and through computerized questionnaires. However, if the method of collection produces different results, medical decisions regarding appropriate and cost-effective care may be influenced by collection method. We conducted an experiment where subjects had two quality of life measures, the time trade-off and rating scale utilities, assessed both in telephone interivews and via computer touchscreens. The order of telephone and touchscreen was randomized. We found that rating scale utilities were similar whether obtained via the telephone or via touchscreen regardless of which was done first. However, patients who had their time trade-off utilities assessed over the telephone first did not provide as consistent responses as those elicited first via touchscreen (p = 0.01). Caution is suggested when considering eliciting time trade-off over the telephone with subjects who have not had time trade-off elicited previously.
PMCID: PMC2232849  PMID: 10566368
3.  Acceptability of the Talking Touchscreen for Health Literacy Assessment 
Journal of Health Communication  2010;15(Suppl 2):80-92.
Self-administration of a multimedia health literacy measure in clinic settings is a novel concept. Demonstrated ease of use and acceptability will help predicate the future value of this strategy. We previously demonstrated the acceptability of a “Talking Touchscreen” for health status assessment. For this study, we adapted the touchscreen for self-administration of a new health literacy measure. Primary care patients (n=610) in clinics for underserved populations completed health status and health literacy questions on the Talking Touchscreen and participated in an interview. Participants were 51% female, 10% age 60+, 67% African American, 18% without a high school education, and 14% who had never used a computer. The majority (93%) had no difficulty using the touchscreen, including those who were computer-naïve (87%). Most rated the screen design as very good or excellent (72%), including computer-naïve patients (71%) and older patients (75%). Acceptability of the touchscreen did not differ by health literacy level. The Talking Touchscreen was easy to use and acceptable for self-administration of a new health literacy measure. Self-administration should reduce staff burden and costs, interview bias, and feelings of embarrassment by those with lower literacy. Tools like the Talking Touchscreen may increase exposure of underserved populations to new technologies.
PMCID: PMC3269098  PMID: 20845195
Computer Literacy; Health Literacy; User-Computer Interface; Multimedia; Vulnerable Populations
4.  Spatio-Temporal Features of Visual Exploration in Unilaterally Brain-Damaged Subjects with or without Neglect: Results from a Touchscreen Test 
PLoS ONE  2012;7(2):e31511.
Cognitive assessment in a clinical setting is generally made by pencil-and-paper tests, while computer-based tests enable the measurement and the extraction of additional performance indexes. Previous studies have demonstrated that in a research context exploration deficits occur also in patients without evidence of unilateral neglect at pencil-and-paper tests. The objective of this study is to apply a touchscreen-based cancellation test, feasible also in a clinical context, to large groups of control subjects and unilaterally brain-damaged patients, with and without unilateral spatial neglect (USN), in order to assess disturbances of the exploratory skills. A computerized cancellation test on a touchscreen interface was used for assessing the performance of 119 neurologically unimpaired control subjects and 193 patients with unilateral right or left hemispheric brain damage, either with or without USN. A set of performance indexes were defined including Latency, Proximity, Crossings and their spatial lateral gradients, and Preferred Search Direction. Classic outcome scores were computed as well. Results show statistically significant differences among groups (assumed p<0.05). Right-brain-damaged patients with USN were significantly slower (median latency per detected item was 1.18 s) and less efficient (about 13 search-path crossings) in the search than controls (median latency 0.64 s; about 3 crossings). Their preferred search direction (53.6% downward, 36.7% leftward) was different from the one in control patients (88.2% downward, 2.1% leftward). Right-brain-damaged patients without USN showed a significantly abnormal behavior (median latency 0.84 s, about 5 crossings, 83.3% downward and 9.1% leftward direction) situated half way between controls and right-brain-damaged patients with USN. Left-brain-damaged patients without USN were significantly slower and less efficient than controls (latency 1.19 s, about 7 crossings), preserving a normal preferred search direction (93.7% downward). Therefore, the proposed touchscreen-based assessment had evidenced disorders in spatial exploration also in patients without clinically diagnosed USN.
PMCID: PMC3275551  PMID: 22347489
5.  Using Information Technology to Reduce Asthma Disparities in Underserved Populations: A Pilot Study 
Low health literacy has been identified as an independent predictor of poor asthma control. The Institute of Medicine considers the role of information technology (IT) as critical in providing “safe, effective, patient centered, timely, efficient, and equitable” care with the potential to reduce health disparities in underserved populations. The aim of this study was to design and evaluate an interactive computer-based questionnaire to assess asthma symptoms in children of parents with limited health literacy and/or limited English proficiency.
Volunteer caregivers attending a mobile asthma clinic were randomly assigned to complete the electronic or the paper-and-pencil version of an asthma screening questionnaire (ASQ) in their language of choice (English or Spanish). In the electronic version, a tablet computer was used to present the ASQ questions as video clips and to collect information through the touchscreen. Participants also completed a demographic questionnaire, a brief health literacy questionnaire, and a system usability and satisfaction questionnaire. Reliability of the paper and electronic self-assessments was evaluated by comparing each participant’s answers to information they provided during a nurse-guided structured interview (gold standard).
A total of 48 parents participated in the study, 26 completed the electronic ASQ and 21 the paper-and-pencil form. Thirty-five percent of the children had well-controlled asthma (n = 17). Most participants were Spanish speaking (67%) Hispanic (n = 44) mothers (n = 43) with a median age of 32 years. More than half had ≤8 years of education (n = 25) and earned <$20,000 per year (n = 27). The median health literacy score was 32 (range 0 36). The correlation between health literacy scores and years of education was significant (p = .47, p < .01). Concordance between the electronic ASQ and the nurse interview was significantly higher than concordance between the paper ASQ and the nurse interview (68% versus 54%; p < .01). All parents who completed the electronic questionnaire reported being satisfied; 96% felt comfortable using it, and found it simple to use.
By facilitating the assessment of asthma symptoms at manageable cost, interactive information technology tools may help reduce barriers to access due to inadequate levels of English proficiency and health literacy.
PMCID: PMC3007599  PMID: 20846082
asthma; children; computer-based assessment; English proficiency; health literacy; parents; self-report
6.  Feasibility of Computer-Based Self-Administered Cancer-Specific Geriatric Assessment in Older Patients With Gastrointestinal Malignancy 
The Oncologist  2013;18(1):64-72.
A computer-based cancer specific geriatric assessment was developed and tested among patients age 70 and older receiving treatment for gastrointestinal malignancies at the Dana-Farber Cancer Institute. The feasibility endpoints were met, although half of the sample required assistance and the results did not affect immediate clinical decision-making.
The Cancer-Specific Geriatric Assessment (CSGA) is a primarily self-administered paper survey of validated measures.
We developed and tested the feasibility of a computer-based CSGA in patients ≥70 years of age who were receiving treatment for gastrointestinal malignancies at the Dana-Farber Cancer Institute. From December 2009 to June 2011, patients were invited to complete the CSGA at baseline (start of new treatment) and follow-up (at the first of 4 months later or within 4 weeks of completing treatment). Feasibility endpoints were proportion of eligible patients consented, proportion completing CSGA at baseline and follow-up, time to complete CSGA, and proportion of physicians reporting CSGA results that led to a change in clinical decision-making.
Of the 49 eligible patients, 38 consented (76% were treatment naive). Median age was 77 years (range: 70–89 years), and 48% were diagnosed with colorectal cancer. Mean physician-rated Karnofsky Performance Status was 87.5 at baseline (SD 8.4) and 83.5 at follow-up (SD 8). At baseline, 92% used a touchscreen computer; 97% completed the CSGA (51% independently). At follow-up, all patients used a touchscreen computer; 71% completed the CSGA (41% independently). Mean time to completion was 23 minutes at baseline (SD 8.4) and 20 minutes at follow-up (SD 5.1). The CSGA added information to clinical assessment for 75% at baseline (n = 27) and 65% at follow-up (n = 17), but it did not alter immediate clinical decision-making.
The computer-based CSGA feasibility endpoints were met, although approximately half of patients required assistance. The CSGA added information to clinical assessment but did not affect clinical decision-making, possibly due to limited alternate treatment options in this subset of patients.
PMCID: PMC3556258  PMID: 23287880
Gastrointestinal cancer; Geriatric oncology; Geriatric assessment; Clinical decision-making
7.  Radiation oncology outpatient perceptions of patient-centred care: a cross-sectional survey 
BMJ Open  2013;3(2):e001265.
We aimed to describe the proportion and characteristics of cancer patients who perceived that better care would have greatly improved their well-being in (1) specific and (2) multiple domains of patient-centred care.
Cross-sectional touchscreen computer survey.
Four Australian radiation therapy departments located within major urban public hospitals.
Radiation therapy outpatients were invited to participate in a touchscreen computer survey. Eligible patients were at least 18 years old, diagnosed with cancer and had sufficient English to complete the survey.
Primary outcome measure
Participants were asked whether their well-being could have been greatly improved if better care had been provided across eight domains of patient-centred care. Characteristics of those respondents who identified (1) specific and (2) multiple domains where it was perceived that better care would have greatly improved their well-being were examined.
Of 508 eligible radiation therapy patients, 344 (68%) completed the survey. Patients most frequently perceived that better care in the following domains could have improved their well-being: information and communication about their cancer (22%; 95% CI 18% to 27%); emotional and spiritual support (22%; 95% CI 18% to 27%); management of physical symptoms (21%; 95% CI 17% to 26%) and involvement of friends and family (21%; 95% CI 17% to 26%). Just under one-third of respondents (31%; 95% CI 26% to 36%) indicated that their well-being could have been improved by better care across two or more domains of care. Patients in younger age groups and migrants to Australia had higher odds of endorsing multiple domains where better care would have improved their well-being.
Further investigation of patients’ perceptions of how their perceived quality of care might be improved is warranted, particularly among patients in younger age groups and migrants to Australia.
PMCID: PMC3586157  PMID: 23427199
Patient-Centered Care; Cross-Sectional Studies; Neoplasms; Health Care Quality, Access, and Evaluation
8.  The use of patient-reported outcomes becomes standard practice in the routine clinical care of lung–heart transplant patients 
To assess the use of patient-reported outcome (PROs) measures in the routine clinical care of lung–heart transplant patients. We assessed whether the addition of PROs in routine clinical care affected the duration of the consultation and patient’s and clinician’s views.
Consecutive lung–heart transplant patients visiting the outpatient clinic, University of Alberta Hospital, completed the Chronic Respiratory Questionnaire (CRQ) and the Health Utilities Index (HUI) on touchscreen computers. Information on the patient’s responses was made available to the members of the transplant team prior to the encounter with the patient. The duration of clinical encounters was noted. At the end of every visit, clinicians completed a questionnaire on the usefulness of having PRO information available. After 6 months patients completed a survey of their experiences.
The final patient sample consisted of 172 patients with a mean (SD) age of 52 (13.3) years old; 47% were female; 68% were organ recipients and 32% candidates. The transplant team, comprising four pulmunologists, two nurses, and one pharmacist had an average of 9 years of practical experience in pulmunology. The mean duration of patient–clinician encounters in minutes was 15.15 (4.52). Ninety-eight percent of patients indicated that they would be happy to complete the CRQ and HUI at every clinic visit. Ninety-one percent of the assessments completed by clinicians showed complete satisfaction with the use of PROs in routine practice. Further, the clinicians developed guidelines for the use of PRO information in clinical practice.
The incorporation of PRO measures in the routine clinical care of lung–heart transplant patients resulted in a reduction of the duration of patient–clinician encounters. The experience was well accepted by patients and clinicians. We conclude that the routine use of PROs in lung–heart transplant patients has become standard practice.
PMCID: PMC3417902  PMID: 22915956
patient-reported outcome measures; Chronic Respiratory Questionnaire; Health Utilities Index; routine clinical care; lung transplant
9.  Remote Speech and Language Therapy services in Buckinghamshire 
Executive summary
Speech and Language Therapists work with people with aphasia following Stroke. For many clients aphasia is a life-long condition and an individual’s ability to adjust to this is very variable. Buckinghamshire Healthcare Trust has an integrated adult Speech and Language Therapy (SLT) Service with 3.6 WTE therapists allocated to the Community Long-Term Conditions Team which serves patients with aphasia as well as other conditions including dementia and progressive neurological conditions. Obviously there is a limit in the capacity of this service and we need to look to alternative and innovative methods of service provision. These have included:
group therapy
strengthen links with the voluntary sector
Conversation Partner Scheme training volunteers to visit people in their own homes
Strategic context
A local healthcare need was identified by Buckinghamshire County Council (BCC); difficulty accessing intensive SLT for clients with aphasia post stroke. BCC had experience and expertise in Telecare/Telehealth and wanted to extend the role of Telehealth to these clients, funding was identified. BCC and the SLT Department worked together for several months identifying the best quality package for people with aphasia. This was potentially very exciting but the initial concept required adjustment as the current Telecare was not sophisticated enough to cope with the data produced by complex aphasia computer therapy. An additional partner was brought in ‘Steps Consultancy’ and this enabled us to produce a package which achieved our initial objective. The provision of the following is secure for 3 years: 7 MSI touchscreen computers (with keyboard and mouse). Three laptops and laptop bags. Multiple user Licence for Step-By-Step software. Licence x8 REACT software. Ten finger scanners, microphones and headphones. Contract with a local company for hardware support. Continued software support form Steps including staff training.
Case for change
Currently we are set up to begin using the devices remotely, this took a lot of technical work with Steps Consultancy and Buckinghamshire Healthcare Trust (BHT) IT Department. SLT staff was trained in software use but are not yet highly familiar with the package. All devices were assigned to clients and we are in the process of setting these clients up with a system by connecting the device to the central server through their home internet system. The outdated IT equipment we are trying to use within the Trust is slowing us down. Also, due to staffing constraints in the department the assessment of patients, setting up of the programme, delivering and setting up the equipment and the following up on results and updating therapy packages is time consuming and has been difficult to absorb into our current capacity, but we are making progress.
To provide people with aphasia access to Teletherapy so that they can increase the amount of therapy practice.
Service Proposal for stage 2
The SLT department has identified 3.75 hours a week of therapy time to dedicate to the Teletherapy Project, this will be subject to BHT approval, if approved will commence January 2012. This is in order to use the equipment to its full potential and achieve timely distribution of computer therapy packages. We have concerns that, as all touchscreens are allocated to patients, and patients keep the screens for approximately 6 months there is going to be a waiting list for equipment as we receive new referrals for Teletherapy. The SLT Department proposes further development of the project in the following ways:
investment in upgrading the project to teleconferencing to use the equipment we currently have to its full potential. This would involve investment in Broadband, new up to date Windows7 PCs and 24” monitors (3 of each), webcams and appropriate software to allow teleconferencing;
purchasing a further 10 touchscreen computers so that the programme is available to new strokes without having to go on a waiting list;
increased consultancy fee to Steps so that we can have mentorship of our new post-holder who will have 3.75 hours per week allocated to the project;
to provide SLT services to other neuro-conditions that result in a SLT requirement;
integration of telehealth service into existing community equipment services and countywide Telehealth monitoring contract to test model for Telehealth at scale in next 12–24 months.
PMCID: PMC3571123
telehealth; speech and language therapy; joint commissioning
10.  Patient-reported outcome 2 years after lung transplantation: does the underlying diagnosis matter? 
Transplantation has the potential to produce profound effects on survival and health-related quality of life (HRQL). The inclusion of the patient’s perspective may play an important role in the assessment of the effectiveness of lung transplantation. Patient perspectives are assessed by patient-reported outcome measures, including HRQL measures. We describe how patients’ HRQL among different diagnosis groups can be used by clinicians to monitor and evaluate the outcomes associated with transplantation.
Consecutive lung transplant recipients attending the lung transplant outpatient clinic in a tertiary institution completed the 15-item Health Utilities Index (HUI) questionnaire on a touchscreen computer. The results were available to clinicians at every patient visit. The HUI3 covers a range of severity and comorbidities in eight dimensions of health status. Overall HUI3 scores are on a scale in which dead = 0.00 and perfect health = 1.00; disability categories range from no disability = 1 to severe disability <0.70. Single-attribute and overall HUI3 scores were used to compare patients’ HRQL among different diagnosis groups. Random-effect models with time since transplant as a random variable and age, gender, underlying diagnoses, infections, and broncholitis obliterans syndrome as fixed variables were built to identify determinants of health status at 2-years posttransplantation.
Two hundred and fourteen lung transplant recipients of whom 61% were male with a mean age of 52 (19–75) years were included in the study. Chronic obstructive pulmonary disease and cystic fibrosis patients displayed moderate disability, while pulmonary fibrosis and pulmonary arterial hypertension patients displayed severe disability. Patients with chronic obstructive pulmonary disease had the worst pain level, whereas patients with pulmonary fibrosis had the worst emotion and cognition levels. A random-effect model confirmed that development of broncholitis obliterans syndrome was the most important determinant of health status (P = 0.03) compared to other variables, such as cytomegalovirus infections and underlying diagnoses.
Descriptions of patients’ HRQL among different diagnosis groups could be used by clinicians to assist individualized patient care.
PMCID: PMC3508652  PMID: 23204877
patient-reported outcomes; health-related quality of life measures; underlying diagnoses in lung transplant recipients; health utilities index
11.  Validating automated screening for psychological distress by means of computer touchscreens for use in routine oncology practice 
British Journal of Cancer  2001;85(12):1842-1849.
The aim of the study was to confirm the validity of using touchscreen computers for screening for clinically significant levels of distress among cancer patients in routine oncology practice. The Hospital Anxiety and Depression Scale (HADS), EORTC Quality of Life questionnaire (QLQ-C30), Mental Health Inventory-MHI5 and a Concerns Checklist were administered via touchscreen computer to 172 chemotherapy out-patients, twice, 2–4 weeks apart. A standard psychiatric interview (Present State Examination – PSE) was conducted within a week of the second assessment. On interview, 23% of patients were identified as ‘cases’. Using the available data (questionnaires, sociodemographic details, self-reported past psychiatric history), the best screening strategy combined scores from MHI-5 and HADS from a single time-point with the following rules: if MHI-5 < 11 = non-case; if MHI-5 ≥ 11 then use HADS; then, if HADS ≥ 9 = ‘case’ (sensitivity 85%; specificity 71%; misclassification rate 26%; positive predictive value 47%). The computerized screening system enabled data to be collected, scored, collated and reported in real time to identify patients who warrant further clinical assessment. It offers the potential for improving ‘case’ detection in routine oncology practice while reducing the burden of questions put to ‘non-cases’. Further work is needed to develop optimal choice of screening questions for this purpose. © 2001 Cancer Research Campaign
PMCID: PMC2364000  PMID: 11747324
screening; psychological distress; computer touchscreens; routine practice; oncology
12.  Efficacy of a touchscreen computer based family cancer history questionnaire and subsequent cancer risk assessment 
Journal of Medical Genetics  2000;37(5):354-360.
OBJECTIVE—A computer based touchscreen family cancer history questionnaire was developed and implemented to facilitate the provision of cancer risk assessments for the ambulatory and outpatient populations of a free standing cancer hospital.
METHODS—A questionnaire consisting of a series of branched point decision making screens was developed which enables the participant to enter demographic data, personal cancer history, and cancer histories for first and second degree relatives. A freestanding touchscreen computer kiosk system was used to place the questionnaire in public areas of the cancer hospital and clinic. Genetic professionals analysed the data received, using published criteria, and provided a basic cancer risk assessment and surveillance recommendations within 10 business days. A survey was completed by a small random group of users (n=59) three to six months after receipt of their risk assessment. 
RESULTS—After 11 months, 1440 people had entered information and received a written communication. Only 2% of completed questionnaires contained insufficient information to provide a basic risk assessment. Of the small group of participants surveyed, almost all (95%) felt "very comfortable" using the system, 93% remembered receiving the risk assessment letter when queried three to six months later, 42% felt their perceptions about cancer risk had changed, and 20% had made changes in their or their family's cancer surveillance practices. 
CONCLUSION—The touchscreen computer family history questionnaire allows easy collection of family history information, provision of risk assessments to a broad population, and promotes increased awareness of familial risk and appropriate surveillance.

Keywords: genetic counselling; risk assessment; computers; medical informatics
PMCID: PMC1734575  PMID: 10807694
13.  The accessibility of information systems for patients: use of touchscreen information systems by 345 patients with cancer in Scotland. 
AIM: To examine cancer patients' use, and satisfaction with touchscreen information systems. By examining the experience of subgroups, to address issues of equality of access. PATIENTS: 345 patients starting radiotherapy at the Beatson Oncology Centre (BOC), Glasgow. METHODS: Patients were invited to use a touchscreen computer at the start of treatment. They were sent a printout of what they saw on screen. Patients had open access to the system. Data were collected at recruitment, intervention, 3 weeks and 3 months. Predictor variables included: patients' demographics, information preferences, technology use, and psychological state. Outcome variables included: use and views of the computer and printout. RESULTS: Younger, broadsheet readers with previous computer use were more likely to find the system easy to use. Older, tabloid readers were more likely to find the content new and relevant. DISCUSSION: We need to make systems adapt to users' different needs. More effort should be made to provide affordable information for older, generally less literate and technologically less literate groups in suitable locations.
PMCID: PMC2232486  PMID: 10566428
14.  Physician use of an NICU laboratory reporting system. 
Clinical workstation developers may gain useful insights from studies of physician acceptance and use of computer systems that have been incorporated into daily practice. We used a physician survey, intrinsic monitors built into the system and an observational study to assess physician acceptance and use of a touchscreen workstation that was put in place in an NICU in 1985. Each of the 87 physicians assigned to the 30 bed NICU during the two academic years beginning July, 1987 was sent a questionnaire that assessed experience and attitudes about the system. The 70 responding physicians (80 percent) were unanimous in agreeing or strongly agreeing that the system was "easy to learn" (57 reported it taking less than five minutes), "easy to use", and "integrates smoothly into patient care activities". Over 94 percent of the physicians agreed or strongly agreed that the system was "fast", "saves time", and was "reliable and dependable." Sixty-three of the responding physicians (90%) reported using the system two or more times a day with 53 using it more than five times daily. The most frequently requested new feature was that of time-trend graphs (51 occurrences). The intrinsic monitors were useful in validating design decisions and survey results but also provided new insights relevant to security issues. Similarly, the observation study reinforced some of the survey results but also highlighted an additional issue not brought out by the other two assessment methods. The overall assessment indicated that the system has been both well-accepted and well-used by its intended clinical clientele.
PMCID: PMC2248125  PMID: 1482988
15.  Practicability of Hygienic Wrapping of Touchscreen Operated Mobile Devices in a Clinical Setting 
PLoS ONE  2014;9(9):e106445.
To prove effectiveness of wrapping tablet computers in order to reduce microbiological contamination and to evaluate whether a plastic bag-covered tablet leads to impaired user satisfaction or touchscreen functionality.
Materials and Methods
Within a period of 11 days 115 patients were provided with a tablet computer while waiting for their magnetic resonance imaging examination. Every day the contamination of the surface of the tablet was determined before the first and after the final use. Before the device was handed over to a patient, it was enclosed in a customized single-use plastic bag, which was analyzed for bacterial contamination after each use. A questionnaire was applied to determine whether the plastic bag impairs the user satisfaction and the functionality of the touchscreen.
Following the use by patients the outside of the plastic bags was found to be contaminated with various bacteria (657.5 ± 368.5 colony forming units/day); some of them were potentially pathogenic. In contrast, the plastic bag covered surface of the tablet was significantly less contaminated (1.7 ± 1.9 colony forming units/day). Likewise, unused plastic bags did not show any contamination. 11% of the patients reported problems with the functionality of the touchscreen. These patients admitted that they had never used a tablet or a smartphone before.
Tablets get severely contaminated during usage in a clinical setting. Wrapping with a customized single-use plastic bag significantly reduces microbiological contamination of the device, protects patients from the acquisition of potentially pathogenic bacteria and hardly impairs the user satisfaction and the functionality of the touchscreen.
PMCID: PMC4152284  PMID: 25180580
16.  Health Literacy Assessment Using Talking Touchscreen Technology (Health LiTT): A New Item Response Theory-based Measure of Health Literacy 
Journal of Health Communication  2011;16(Suppl 3):150-162.
The importance of health literacy has grown considerably among researchers, clinicians, patients and policymakers. Better instruments and measurement strategies are needed. Our objective was to develop a new health literacy instrument using novel health information technology and modern psychometrics. We designed Health LiTT as a self-administered multimedia touchscreen test based on item response theory (IRT) principles. We enrolled a diverse group of 619 English-speaking primary care patients in clinics for underserved patients. We tested three item types (prose, document, quantitative) that worked well together to reliably measure a single dimension of health literacy. The Health LiTT score meets psychometric standards (reliability of 0.90 or higher) for measurement of individual respondents in the low to middle range. Mean Health LiTT scores were associated with age, race/ethnicity, education, income and prior computer use (p<0.05). We created an IRT-calibrated item bank of 82 items. Standard setting needs to be performed to classify and map items onto the construct and to identify measurement gaps. We are incorporating Health LiTT into an existing online research management tool. This will enable administration of Health LiTT on the same touchscreen used for other patient-reported outcomes, as well as real-time scoring and reporting of health literacy scores.
PMCID: PMC3269120  PMID: 21951249
17.  Access to chronic disease care in general practice: the acceptability of implementing systematic waiting-room screening using computer-based patient-reported risk status 
The British Journal of General Practice  2013;63(614):e620-e626.
Routine screening and advice regarding risky lifestyle behaviours is appropriate in the primary care setting, but often not implemented. Routine electronic collection of patients’ self-reported data may streamline the collection of such information.
To explore the perceptions of GPs and their attending patients regarding the acceptability of waiting-room touchscreen computers for the collection of health behaviour information. Uptake, ease of operation, and the perceived likelihood of future implementation were studied.
Design and setting
Cross-sectional health-risk survey. General practices in metropolitan areas in Australia.
Practices were randomly selected by postcode. Consecutive patients who were eligible to take part in the study were approached in the waiting room and invited to do so. Participants completed the touchscreen health survey. A subsample of patients and GPs completed additional items regarding acceptability.
Twelve general practices participated in the study, with 4058 patients (86%) and 51 of 68 (75%) GPs consenting to complete the health-risk survey, 596 patients and 30 GPs were selected to complete the acceptability survey. A majority of the 30 GPs indicated that the operation of the survey was not disruptive to practice and more than 90% of patients responded positively to all items regarding its operation. More than three-quarters of the patient sample were willing to consider allowing their responses to be kept on file and complete such surveys in the future.
As waiting-room-based collection of this information appears to be both feasible and acceptable, practitioners should consider collecting and incorporating routine patient-reported health behaviours for inclusion in the medical record.
PMCID: PMC3750801  PMID: 23998842
acceptability; chronic disease; e-health; general practice; primary care; touchscreen computer
18.  Bilingual health literacy assessment using the Talking Touchscreen/la Pantalla Parlanchina: Development and pilot testing 
Patient education and counseling  2009;75(3):295-301.
Current health literacy measures are too long, imprecise, or have questionable equivalence of English and Spanish versions. The purpose of this paper is to describe the development and pilot testing of a new bilingual computer-based health literacy assessment tool.
We analyzed literacy data from three large studies. Using a working definition of health literacy, we developed new prose, document and quantitative items in English and Spanish. Items were pilot tested on 97 English- and 134 Spanish-speaking participants to assess item difficulty.
Items covered topics relevant to primary care patients and providers. English- and Spanish-speaking participants understood the tasks involved in answering each type of question. The English Talking Touchscreen was easy to use and the English and Spanish items provided good coverage of the difficulty continuum.
Qualitative and quantitative results provided useful information on computer acceptability and initial item difficulty. After the items have been administered on the Talking Touchscreen (la Pantalla Parlanchina) to 600 English-speaking (and 600 Spanish-speaking) primary care patients, we will develop a computer adaptive test.
Practice Implications
This health literacy tool will enable clinicians and researchers to more precisely the level at which low health literacy adversely affects health and healthcare utilization.
PMCID: PMC2692378  PMID: 19386462
literacy; multimedia; ethnic groups; psychometrics
19.  The hippocampus is required for visually cued contextual response selection, but not for visual discrimination of contexts 
The hippocampus is important for spatial navigation. Literature shows that allocentric visual contexts in the animal's background are critical for making conditional response selections during navigations. In a traditional maze task, however, it is difficult to identify exactly which subsets of visual contexts are critically used. In the current study, we tested in rats whether making conditional response selections required the hippocampus when using computer-generated visual contextual stimuli in the animal's background as in primate and human studies. We designed a new task, visual contextual response selection (VCRS) task, in which the rat ran along a linear track and encountered a touchscreen monitor at the end of the track. The rat was required to touch one of the adjacent rectangular box images depending on the visual contextual stimuli displayed in the two peripheral monitors positioned on both sides of the center touchscreen monitor. The rats with a GABA-A receptor agonist, muscimol (MUS), infused bilaterally in the dorsal hippocampi showed severe performance deficits in the VCRS task and the impairment was completely reversible with vehicle injections. The impairment in contextual response selection with hippocampal inactivations occurred regardless of whether the visual context was presented in the side monitors or in the center touchscreen monitor. However, when the same visual contextual stimuli were pitted against each other between the two side monitors and as the rats simply ran toward the visual context associated with reward on a T-shaped track, hippocampal inactivations with MUS showed minimal disruptions, if any, in performance. Our results suggest that the hippocampus is critically involved in conditional response selection using visual stimuli in the background, but it is not required for the perceptual discrimination of those stimuli.
PMCID: PMC3460488  PMID: 23060765
hippocampus; context; navigation; episodic memory; response selection; choice behavior; decision making
20.  Intact attentional processing but abnormal responding in M1 muscarinic receptor-deficient mice using an automated touchscreen method 
Neuropharmacology  2011;61(8):1366-1378.
Cholinergic receptors have been implicated in schizophrenia, Alzheimer’s disease, Parkinson’s disease, and Huntington’s disease. However, to better target therapeutically the appropriate receptor subsystems, we need to understand more about the functions of those subsystems. In the current series of experiments, we assessed the functional role of M1 receptors in cognition by testing M1 receptor-deficient mice (M1R−/−) on the five-choice serial reaction time test of attentional and response functions, carried out using a computer-automated touchscreen test system. In addition, we tested these mice on several tasks featuring learning, memory and perceptual challenges. An advantage of the touchscreen method is that each test in the battery is carried out in the same task setting, using the same types of stimuli, responses and feedback, thus providing a high level of control and task comparability. The surprising finding, given the predominance of the M1 receptor in cortex, was the complete lack of effect of M1 deletion on measures of attentional function per se. Moreover, M1R−/− mice performed relatively normally on tests of learning, memory and perception, although they were impaired in object recognition memory with, but not without an interposed delay interval. They did, however, show clear abnormalities on a variety of response measures: M1R−/− mice displayed fewer omissions, more premature responses, and increased perseverative responding compared to wild-types. These data suggest that M1R−/− mice display abnormal responding in the face of relatively preserved attention, learning and perception.
PMCID: PMC3899542  PMID: 21903112
21.  Under the radar: a cross-sectional study of the challenge of identifying at-risk alcohol consumption in the general practice setting 
BMC Family Practice  2014;15:74.
Primary care providers are an important source of information regarding appropriate alcohol consumption. As early presentation to a provider for alcohol-related concerns is unlikely, it is important that providers are able to identify at-risk patients in order to provide appropriate advice. This study aimed to report the sensitivity, specificity, positive predictive value and negative predictive value of General Practitioner (GP) assessment of alcohol consumption compared to patient self-report, and explore characteristics associated with GP non-detection of at-risk status.
GP practices were selected from metropolitan and regional locations in Australia. Eligible patients were adults presenting for general practice care who were able to understand English and provide informed consent. Patients completed a modified AUDIT-C by touchscreen computer as part of an omnibus health survey while waiting for their appointment. GPs completed a checklist for each patient, including whether the patient met current Australian guidelines for at-risk alcohol consumption. Patient self-report and GP assessments were compared for each patient.
GPs completed the checklist for 1720 patients, yielding 1565 comparisons regarding alcohol consumption. The sensitivity of GPs’ detection of at-risk alcohol consumption was 26.5%, with specificity of 96.1%. Higher patient education was associated with GP non-detection of at-risk status.
GP awareness of which patients might benefit from advice regarding at-risk alcohol consumption appears low. Given the complexities associated with establishing whether alcohol consumption is ‘at-risk’, computer-based approaches to routine screening of patients are worthy of exploration as a method for prompting the provision of advice in primary care.
PMCID: PMC4004529  PMID: 24766913
General practice; Alcohol; Detection; Accuracy; Sensitivity
22.  Point-of-care, peer-comparator colonoscopy practice audit: The Canadian Association of Gastroenterology Quality Program – Endoscopy 
Point-of-care practice audits allow documentation of procedural outcomes to support quality improvement in endoscopic practice.
To evaluate a colonoscopists’ practice audit tool that provides point-of-care data collection and peer-comparator feedback.
A prospective, observational colonoscopy practice audit was conducted in academic and community endoscopy units for unselected patients undergoing colonoscopy. Anonymized colonoscopist, patient and practice data were collected using touchscreen smart-phones with automated data upload for data analysis and review by participants. The main outcome measures were the following colonoscopy quality indicators: colonoscope insertion and withdrawal times, bowel preparation quality, sedation, immediate complications and polypectomy, and biopsy rates.
Over a span of 16 months, 62 endoscopists reported on 1279 colonoscopy procedures. The mean cecal intubation rate was 94.9% (10th centile 84.2%). The mean withdrawal time was 8.8 min and, for nonpolypectomy colonoscopies, 41.9% of colonoscopists reported a mean withdrawal time of less than 6 min. Polypectomy was performed in 37% of colonoscopies. Independent predictors of polypectomy included the following: endoscopy unit type, patient age, interval since previous colonoscopy, bowel preparation quality, stable inflammatory bowel disease, previous colon polyps and withdrawal time. Withdrawal times of less than 6 min were associated with lower polyp removal rates (mean difference −11.3% [95% CI −2.8% to −19.9%]; P=0.01).
Cecal intubation rates exceeded 90% and polypectomy rates exceeded 30%, but withdrawal times were frequently shorter than recommended. There are marked practice variations consistent with previous observations.
Real-time, point-of-care practice audits with prompt, confidential access to outcome data provide a basis for targeted educational programs to improve quality in colonoscopy practice.
PMCID: PMC3027329  PMID: 21258663
Colonoscopy; Health care; Practice audit; Quality assurance; Quality indicators
23.  Artificial Discs for Lumbar and Cervical Degenerative Disc Disease –Update 
Executive Summary
To assess the safety and efficacy of artificial disc replacement (ADR) technology for degenerative disc disease (DDD).
Clinical Need
Degenerative disc disease is the term used to describe the deterioration of 1 or more intervertebral discs of the spine. The prevalence of DDD is roughly described in proportion to age such that 40% of people aged 40 years have DDD, increasing to 80% among those aged 80 years or older. Low back pain is a common symptom of lumbar DDD; neck and arm pain are common symptoms of cervical DDD. Nonsurgical treatments can be used to relieve pain and minimize disability associated with DDD. However, it is estimated that about 10% to 20% of people with lumbar DDD and up to 30% with cervical DDD will be unresponsive to nonsurgical treatments. In these cases, surgical treatment is considered. Spinal fusion (arthrodesis) is the process of fusing or joining 2 bones and is considered the surgical gold standard for DDD.
Artificial disc replacement is the replacement of the degenerated intervertebral disc with an artificial disc in people with DDD of the lumbar or cervical spine that has been unresponsive to nonsurgical treatments for at least 6 months. Unlike spinal fusion, ADR preserves movement of the spine, which is thought to reduce or prevent the development of adjacent segment degeneration. Additionally, a bone graft is not required for ADR, and this alleviates complications, including bone graft donor site pain and pseudoarthrosis. It is estimated that about 5% of patients who require surgery for DDD will be candidates for ADR.
Review Strategy
The Medical Advisory Secretariat conducted a computerized search of the literature published between 2003 and September 2005 to answer the following questions:
What is the effectiveness of ADR in people with DDD of the lumbar or cervical regions of the spine compared with spinal fusion surgery?
Does an artificial disc reduce the incidence of adjacent segment degeneration (ASD) compared with spinal fusion?
What is the rate of major complications (device failure, reoperation) with artificial discs compared with surgical spinal fusion?
One reviewer evaluated the internal validity of the primary studies using the criteria outlined in the Cochrane Musculoskeletal Injuries Group Quality Assessment Tool. The quality of concealment allocation was rated as: A, clearly yes; B, unclear; or C, clearly no. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to evaluate the overall quality of the body of evidence (defined as 1 or more studies) supporting the research questions explored in this systematic review. A random effects model meta-analysis was conducted when data were available from 2 or more randomized controlled trials (RCTs) and when there was no statistical and or clinical heterogeneity among studies. Bayesian analyses were undertaken to do the following:
Examine the influence of missing data on clinical success rates;
Compute the probability that artificial discs were superior to spinal fusion (on the basis of clinical success rates);
Examine whether the results were sensitive to the choice of noninferiority margin.
Summary of Findings
The literature search yielded 140 citations. Of these, 1 Cochrane systematic review, 1 RCT, and 10 case series were included in this review. Unpublished data from an RCT reported in the grey literature were obtained from the manufacturer of the device. The search also yielded 8 health technology assessments evaluating ADR that are also included in this review.
Six of the 8 health technology assessments concluded that there is insufficient evidence to support the use of either lumbar or cervical ADR. The results of the remaining 2 assessments (one each for lumbar and cervical ADR) led to a National Institute for Clinical Excellence guidance document supporting the safety and effectiveness of lumbar and cervical ADR with the proviso that an ongoing audit of all clinical outcomes be undertaken owing to a lack of long-term outcome data from clinical trials.
Regarding lumbar ADR, data were available from 2 noninferiority RCTs to complete a meta-analysis. The following clinical, health systems, and adverse event outcome measures were synthesized: primary outcome of clinical success, Oswestry Disability Index (ODI) scores, pain VAS scores, patient satisfaction, duration of surgery, amount of blood loss, length of hospital stay, rate of device failure, and rate of reoperation.
The meta-analysis of overall clinical success supported the noninferiority of lumbar ADR compared with spinal fusion at 24-month follow-up. Of the remaining clinical outcome measures (ODI, pain VAS scores, SF-36 scores [mental and physical components], patient satisfaction, and return to work status), only patient satisfaction and scores on the physical component scale of the SF-36 questionnaire were significantly improved in favour of lumbar ADR compared with spinal fusion at 24 months follow-up. Blood loss and surgical time showed statistical heterogeneity; therefore, meta-analysis results are not interpretable. Length of hospital stay was significantly shorter in patients receiving the ADR compared with controls. Neither the number of device failures nor the number of neurological complications at 24 months was statistically significantly different between the ADR and fusion treatment groups. However, there was a trend towards fewer neurological complications at 24 months in the ADR treatment group compared with the spinal fusion treatment group.
Results of the Bayesian analyses indicated that the influence of missing data on the outcome measure of clinical success was minimal. The Bayesian model indicated that the probability for ADR being better than spinal fusion was 79%. The probability of ADR being noninferior to spinal fusion using a -10% noninferiority bound was 92%, and using a -15% noninferiority bound was 94%. The probability of artificial discs being superior to spinal fusion in a future trial was 73%.
Six case series were reviewed, mainly to characterize the rate of major complications for lumbar ADR. The Medical Advisory Secretariat defined a major complication as any reoperation; device failure necessitating a revision, removal or reoperation; or life-threatening event. The rates of major complications ranged from 0% to 13% per device implanted. Only 1 study reported the rate of ASD, which was detected in 2 (2%) of the 100 people 11 years after surgery.
There were no RCT data available for cervical ADR; therefore, data from 4 case series were reviewed for evidence of effectiveness and safety. Because data were sparse, the effectiveness of cervical ADR compared with spinal fusion cannot be determined at this time.
The rate of major complications was assessed up to 2 years after surgery. It was found to range from 0% to 8.1% per device implanted. The rate of ASD is not reported in the clinical trial literature.
The total cost of a lumbar ADR procedure is $15,371 (Cdn; including costs related to the device, physician, and procedure). The total cost of a lumbar fusion surgery procedure is $11,311 (Cdn; including physicians’ and procedural costs).
Lumbar Artificial Disc Replacement
Since the 2004 Medical Advisory Secretariat health technology policy assessment, data from 2 RCTs and 6 case series assessing the effectiveness and adverse events profile of lumbar ADR to treat DDD has become available. The GRADE quality of this evidence is moderate for effectiveness and for short-term (2-year follow-up) complications; it is very low for ASD.
The effectiveness of lumbar ADR is not inferior to that of spinal fusion for the treatment of lumbar DDD. The rates for device failure and neurological complications 2 years after surgery did not differ between ADR and fusion patients. Based on a Bayesian meta-analysis, lumbar ADR is 79% superior to lumbar spinal fusion.
The rate of major complications after lumbar ADR is between 0% and 13% per device implanted. The rate of ASD in 1 case series was 2% over an 11-year follow-up period.
Outcome data for lumbar ADR beyond a 2-year follow-up are not yet available.
Cervical Artificial Disc Replacement
Since the 2004 Medical Advisory Secretariat health technology policy assessment, 4 case series have been added to the body of evidence assessing the effectiveness and adverse events profile of cervical ADR to treat DDD. The GRADE quality of this evidence is very low for effectiveness as well as for the adverse events profile. Sparse outcome data are available.
Because data are sparse, the effectiveness of cervical ADR compared with spinal fusion cannot be determined at this time.
The rate of major complications was assessed up to 2 years after surgery; it ranged from 0% to 8.1% per device implanted. The rate of ASD is not reported in the clinical trial literature.
PMCID: PMC3379529  PMID: 23074480
24.  Neck of femur fractures in the over 90s: a select group of patients who require prompt surgical intervention for optimal results 
Patients in the extremes of old age with a femoral neck fracture represent a challenging subgroup, and are thought to be associated with poorer outcomes due to increased numbers of comorbidities. Whilst many studies are aimed at determining the optimum time for surgical fixation, there is no agreed consensus for those over 90. The aim of this study is to report the surgical outcome of this population, to understand the role surgical timing may have on operative outcomes using the orthopaedic POSSUM scoring system and to identify whether medical optimization occurs during the period of admission before surgery.
Materials and methods
We conducted a prospective observational study; data was collected from two district general hospitals over 32 consecutive months. All patients aged 90 and above who were deemed suitable for surgical fixation were included. Each one had their orthopaedic POSSUM score calculated at admission and at surgery, using their computerised and paper medical records. Assessment of outcome was based on morbidity and mortality at 30 days.
A total of 146 consecutive patients above the age of 90 underwent surgery and were followed. The average age of the patients was 93 years, 123 (84 %) were female and 23 (16 %) male. Sixty-one patients were operated on within 24 h from admission, 52 patients within 24 and 48 h and 33 had surgery after 48 h from admission. In total, 21 deaths (14.4 %) were recorded and 81 patients (55.5 %) had a post-operative complication within 30 days. The orthopaedic POSSUM scoring system predicted 30-day mortality in 23 patients and morbidity in 83 patients. This gave observed to predicted ratios of 0.91 and 0.98 respectively. Overall, there was a small improvement in physiological scores taken just prior to surgery compared to those at admission. Mortality and morbidity rates were higher for those operated on or after 24 and 48-h cutoffs compared to those proceeding to surgery within 24 h (P = 0.071 and P = 0.021 respectively and P = 0.048 and P = 0.00011 respectively). When stratified according to their POSSUM scores, patients with scores of 41+ and surgery after 48 h had a significantly higher mortality rate than if they had surgery earlier (P = 0.038). Morbidity rates rose after 24 h of surgical delay (P = 0.026). Patients with a total POSSUM score between 33 and 40 exhibited a higher morbidity after a 24-h delay to surgery (P = 0.0064).
As life expectancy increases, older patients are becoming commoner in our hospital systems. We believe the orthopaedic POSSUM scoring system can be used as an adjuvant tool in prioritising surgical need, and allow for a more impartial evaluation when changes to practice are made. Our findings show that timing of surgery has an important bearing on mortality and morbidity after hip surgery, and older patients with higher orthopaedic POSSUM scores are sensitive to delays in surgery.
PMCID: PMC3948521  PMID: 23860690
Fracture neck of femur; Nonagenarians; Timing of surgery
25.  Does Socioeconomic Status Affect Patients’ Ease of Use of a Touch-Screen (iPad) Patient Survey? 
Socioeconomic disparities influence the usage rate of advanced communication technologies in Canada. It is important to assess all patient interactions with computers and electronic devices based on these socioeconomic differences. This project studied the ease of use of a touch-screen interface program for collecting patient feedback. The interface collected feedback on physicians’ communication skills, an important health concern that has been garnering more and more attention. A concurrent paper survey was used to gather information on the socioeconomic status and the usability of the touchscreen device. As expected, patients who were older, had lower annual household income, and had lower educational attainment were associated with more difficulty using the devices. Surprisingly, 94% of all users (representing a wide range of socioeconomic status backgrounds) rated the device as easy to use.
PMCID: PMC3628116  PMID: 23612116
socioeconomic factors; age factors; medical informatics; computer-user interface

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