Central intake systems

Central intake systems, introduced in the United Kingdom , involve placing all referred patients in a waiting list, with subsequent triaging to the most appropriate healthcare provider or service based on their need and disease severity . Patients are coded and tracked through the system to ensure that they receive the right care. This model has been adopted for the management of OA and inflammatory arthritis. A case study, involving document reviews and interviews with clinic managers and healthcare providers in Alberta, Canada, recommends the use of EMRs with an e-referral system to streamline the process . The latter ensures that all relevant data are obtained before a referral is initiated, thereby minimizing delays due to incomplete referrals. Barber et al. have recently developed key performance indicators to evaluate the ability of central intake systems to address key dimensions of quality of care, including appropriateness, accessibility, acceptability, effectiveness and efficiency . Future research using these performance indicators will provide further insight into the effectiveness of this eHealth-enabled MoC. In this context, the use of effectiveness implementation hybrid designs that combine elements of both clinical effectiveness and implementation research to enhance public health impact may be preferable to RCT designs . As the demand for elective joint replacements increases in high-income countries, the use of eHealth-enabled centralised referral systems in public healthcare settings will become increasingly important, to ensure timely access to surgical care and optimise service delivery efficiencies.

Workforce capacity building tools

Building health workforce capacity and capability is essential for sustainable implementation of MSK MoCs . In order to address an important workforce capacity limitation in rheumatoid arthritis (RA) care and to implement the Western Australian Inflammatory Arthritis Model of Care , the Rheumatoid Arthritis for Physiotherapists e-Learning tool (RAP-eL: http://www.rap-el.com.au/ ) was developed. RAP-eL is an interactive, innovative and modular Web-based learning resource developed to improve physiotherapists’ confidence, likely practice behaviours and ability to manage people with RA, and improve their clinical knowledge in several areas of best-practice RA management. RAP-eL has shown effectiveness in achieving these outcomes and has been effectively implemented in upskilling programs for the current physiotherapy workforce undergraduate physiotherapy in Western Australia and Ireland and medical curricula in Victoria, Australia . Successful development and implementation were levered through a cross sector and cross-discipline partnership model that enhanced engagement, professional body support and dissemination, and finally an expanded large-scale roll-out. Google Analytics™ data for January 2014 to April 2016 indicated 12,000 users from 140 nations.

Other point-of-care eHealth tools: movement and computer vision technologies

Recent advances in movement and computer vision technologies have made real-time mobility and movement monitoring in natural settings feasible (e.g. a patient’s performance of home exercise). Such technology can be implemented by clinicians to help lever co-care for patient exercise and activity recommendations that are consistent with the recommendations in MoCs and clinical practice guidelines. This technology allows for provision of real-time feedback on exercise performance in a variety of settings, and on body movement during daily activities. There are two categories of movement sensors: (1) wearables that are based on accelerometer and GPS technologies for whole-body tracking (e.g. Fitbit™) and (2) body segment tracking sensors used in gaming devices (e.g. the Kinect™ sensor). Wearable sensors can measure a person’s movement quality and quantity, offering new ways to understand relationships between activity dose and clinical signs, symptoms and joint damage. Moreover, sensors such as Kinect™ can automatically detect and track the human skeleton in its field of view without the need to wear any markers .

Web-based self-management for arthritis

Contemporary MoCs for arthritis emphasise the importance of supporting patient self-management using a range of resources . Here, eHealth offers a significant opportunity to support self-management approaches. The Internet Chronic Disease Self-Management Program consists of six weekly online workshops moderated by two trained peer moderators . Individuals also log on at least thrice a week to read the online content and join the bulletin board discussion. A 12-month RCT showed a significant improvement in patients’ health distress and participation in stretching and strengthening exercises, compared with the usual care group .

Another online self-management program called RAHelp ( rahelp.org ) was developed by researchers at the University of Missouri. This 10-week Web-based program consisted of self-management modules for patients with RA, a personalized ‘to do’ list, a news feature, a resource library and a journal for tracking the level of pain and stress. An interactive area, the RAHelp Village, offered patients the opportunity to engage in group or individual discussions. Results of an RCT showed that RAHelp improved self-efficacy and quality of life up to 9 months . A subsequent analysis revealed that the burden for administrating the program in the community was low, suggesting that it is feasible to implement more widely . Other flexible platforms that offer personalised self-management support, rather than requiring users to undertake modular training, such as MyJointPain, have also been introduced, with preliminary data suggesting effectiveness in some self-management domains .

For young people with juvenile idiopathic arthritis (JIA) and their parents, Stinson and colleagues developed an online program Teens Taking Charge, which consists of 12 online learning modules covering arthritis, treatment, self-management tips, lifestyles and planning for the future . A separate module was developed for parents to address the impact of arthritis and how to prepare their children to take charge in managing their health. This program was developed and evaluated using a sequential, phased approach consisting of program development, usability testing (ease of use, ease of learning, errors and efficiency) and outcome evaluation (satisfaction with content, user interface and functionality of the program) . Usability testing helps to explore what works, what does not and where gaps in information or functionality exist, as these factors may affect the likelihood that a user will implement the recommendations. A pilot study of 46 patients with JIA across four tertiary care centres showed that implementation was feasible (high compliance, acceptability and satisfaction), with significant improvement in outcomes, including participants’ arthritis knowledge and pain skills. A full-scale RCT is currently underway.

At present, an international Canadian-Australian RCT has been conducted to examine the effect of implementing an online program, People Getting a Grip on Arthritis for RA, using information communication technologies (i.e. Facebook and e-mails) combined with arthritis healthcare professional support and e-educational pamphlets . This partnership approach to co-implementation involves the Arthritis Society in Canada (giving access to the e-program) and arthritis patient organisations in Canada and Australia being engaged to lever recruitment and dissemination of the eHealth intervention.

Online patient decision aids for arthritis care

Patient decision aids are evidence-based tools designed to help patients choose between two or more management options , by helping them to personalize the information about treatment effectiveness, outcomes and the inherent uncertainties of potential benefits versus potential harm. The use of patient decision aids was a response to the shift from traditional authoritative MoCs, in which health professionals make treatment decisions for patients, to shared decision-making . Recently, Li et al. have developed an interactive decision aid for patients who consider methotrexate for RA, called the ANSWER ( answer.arccanada.org ). This eHealth tool was implemented with patients asked to consider two options: (1) use methotrexate as prescribed and (2) ask the doctor to recommend a different medication. The program includes an information module consisting of six animated patient stories illustrating the benefits and side effects of methotrexate, a preference elicitation module guiding the patients to consider the pros and cons of using methotrexate, and a set of health questionnaires. An iterative usability test was conducted with 15 RA patients to ensure smooth navigation and user-friendliness , which are important components of effective implementation. A proof-of-concept study found that the ANSWER reduced patients’ decisional conflict (i.e. the feeling of uncertainty and being unsupported while making a treatment decision) and improved their methotrexate knowledge. Despite these benefits, challenges related to the implementation of patient decision aids in rheumatology practice have been identified, which include rheumatologists being unfamiliar with patient decision aids and the perception that their use may disturb the clinical workflow . The results indicate a need to develop implementation strategies to support integration of this type of tool in clinical practice.

MHealth applications for arthritis care

Several studies have examined the use of smartphones and mobile devices in delivering behaviour change interventions for chronic diseases including arthritis. Fjeldsoe et al. examined the use of short message service (SMS) for supporting healthy behaviours, including smoking cessation, increased physical activity and participation in chronic disease self-management. They also found that tailored content and interactivity were important features of successful SMS interventions. A second review by Wei et al. concurred that the use of SMS could improve individual’s adherence to medication and medical monitoring. However, the integration of smartphones and mobile devices in arthritis service delivery models is at the early stage. Implementation of SMS and e-mail-based interventions will need to address challenges faced by patients and health professionals regarding comfort levels with virtual communication, privacy concerns and additional burdens .

E-registries for skeletal fragility care

Population-level surveillance using e-registries to monitor minimal-trauma fracture epidemiology is important for addressing clinical and population health questions related to post-fracture care and health outcomes at a systems level. This is particularly the case for evaluating contemporary MoCs for osteoporosis, such as the Fracture Liaison Service model , and prospective evaluations of population-based skeletal health, especially in the context of an ageing global population. EHealth systems that offer standardized, efficient data entry, monitoring and management for end users and collection of both clinical and patient-reported outcomes for all fracture sites are necessary to address such important public health issues. This complexity has been difficult to achieve in a single registry until recently, for example, with the introduction of the Swedish Fracture Registry (SFR) . The overall aim of SFR is to improve Swedish health system outcomes by providing population-based data on fracture management in combination with patient-reported health outcomes. The system therefore lends itself well to supporting evaluation of system-wide MoCs for skeletal health.

Wennergren et al. outline the implementation process of the SFR. All system-level health reforms require champions to agitate for change . In the case of the SFR, local orthopaedic surgeons led the development process, supported by project managers and system developers. A governance structure was established and a central agency undertook responsibility to support the SFR. Data entry is Web-based and designed to be simple and intuitive, such as the use of a mouse-pointer to select the location of a fracture(s) from a digital skeleton image. Local implementation was supported in participating hospitals by site visits from SFR staff, consistent with best practice for implementation of new MoCs . Digital tools are being developed to search hospital records for missing fracture cases to work towards 100% incidence accuracy, while partnership opportunities with other professional groups, such as the Swedish Spine Association, are being explored to include other fracture types.

Telehealth for skeletal fragility care

Systematic review-level evidence highlights the effectiveness of telehealth services for the delivery of therapeutic interventions in patients with chronic conditions who live in rural settings . This application is particularly relevant in nations with large landmasses such as Australia and Canada, where care disparities are commonplace, due to geography and a lack of an appropriately skilled health workforce . Notably, the importance of telehealth for skeletal fragility care is reflected in contemporary osteoporosis care strategies that have been developed for health areas , although few studies have examined the effectiveness of this digital technology for osteoporosis care. A recent cluster RCT identified that telephone support from a centralised fracture liaison co-ordinator was associated with improved post-fracture care in facilities that did not have resources or capacity to establish on-site fracture liaison coordinators . Quality assurance data also point to the feasibility of delivering multidisciplinary osteoporosis care through telehealth to communities where access to multidisciplinary health professionals is limited . In this latter example, a formal change management process was undertaken to support implementation of the initiative, including:

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  Formation of a subcommittee to translate the in-person cross-discipline clinical encounters into a telehealth model of service delivery with consideration of consultation and telehealth technical requirements (e.g. various camera angles).

  
  
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  Clinician champions were identified to sit on the subcommittee to ensure engagement from other clinical staff.

  
  
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  Staff interviews were conducted to understand current clinical and administrative practices, and how they could be applied to a telehealth mode.

  
  
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  Training was provided to clinical and administrative staff.

  
  
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  Patient e-resources were developed, such as an online introductory video webcast – a component of care normally undertaken in person by a clinical nurse specialist.

Highlighting the importance of articulating technological innovation with health policy , this project has been integrated as a cornerstone of the Ontario Osteoporosis Strategy , which is fundamental to its sustainability and expansion. Collectively, these data indicate the opportunities that eHealth technologies afford to facilitate the implementation of innovative MoCs for skeletal care and expansion of traditional service delivery models at scale.

Online risk calculators for skeletal fragility care

Several online fracture risk calculators (FRCs) are available to clinicians for this purpose. FRAX ^® is the most widely used fracture risk assessment tool sponsored by the World Health Organization (WHO) ( https://www.shef.ac.uk/FRAX/ ). It combines clinical risk factors with or without BMD data to estimate an individual’s absolute 10-year risk of osteoporotic fracture using country-specific normative data , which now exist for some 56 countries. The Garvan FRC ( http://www.garvan.org.au/promotions/bone-fracture-risk/calculator/ ) is a similar tool and has comparable predictive validity in women . Further country-specific validations are recommended for both tools, and cognisance of their limitations as stand-alone risk assessment tools. Implementation of FRCs at scale is progressing. For end users, FRAX ^® is currently available as an online desktop tool, an offline tool or as a smartphone App (all available at http://www.iofbonehealth.org/osteoporosis-musculoskeletal-disorders/osteoporosis/diagnosis/frax-information-and-resources ). Furthermore, the National Osteoporosis Foundation and the International Society for Clinical Densitometry now recommend FRAX ^® evaluation as a component of bone densitometry . Ultimately, these tools could also be used by patients to judge their skeletal fragility risk and prompt them to seek professional review.

Other point-of-care e-tools for skeletal fragility care

Besides FRCs, other point-of-care e-tools have been showed to improve clinician behaviours related to guideline-consistent care for skeletal fragility, such as EMR reminders , including tools that require real-time entry of patient-reported data. Systematic review-level evidence suggests that clinical outcomes are optimised with tools that target clinician behaviour and patient behaviours, which include multiple combined components, such as information with education .

While intuitively useful and supported by systematic review and meta-analysis-level evidence for improving clinician care in prevention practices, ordering of investigations and prescribing in high-income economies , clinical e-decision support tools vary widely in effectiveness and capacity for sustainable implementation . A key question, therefore, is what makes a clinical e-tool successful in practice? This question remains largely unanswered and is an important research priority area. For example, a systematic review of clinical e-decision support tools for prescribing was unable to determine features of successful implementation , highlighting the need for rigorous implementation research in this area. Common implementation features, whether successful or unsuccessful in implementation outcomes, included:

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  Decision support at the time and place of decision-making

  
  
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  Provision of a recommendation rather than just an assessment

  
  
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  Automatic provision of decision support as part of clinician workflow

  
  
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  Integration with other EMR interfaces (e.g. medicines dispensing)

  
  
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  Convenient locations for the computers (e.g. co-location with clinical assessment rooms).

Furthermore, most of the research in this area appears to be conducted in high-income countries. Transferability to low- and middle-income nations remains an important research question.

MHealth applications for skeletal fragility care

In the context of skeletal health MoCs, eHealth enablers for patients most often focus on optimizing nutrition and supporting safe and effective physical activity. MHealth apps offer a convenient tool for patients to participate in positive health behaviours; a key component of bone health and reflected in osteoporosis and bone healthcare strategies and MoCs. For chronic MSK conditions, however, complex messaging is often required . Whether apps supporting health behaviour change (e.g. exercise and nutrition) are developed in a manner that integrate behaviour change science, clinical evidence and clinical experience remain uncertain .

The Safe-D app was developed in a participatory research model with the aim of preventing vitamin D deficiency (a key factor in skeletal health) in young women. Safe-D encourages safe ultraviolet (UV) radiation exposure through individualized UV exposure recommendations, messages and UV exposure education . Here, balancing complex messages about the importance of UV exposure for vitamin D synthesis against skin cancer safety was considered important, particularly in countries like Australia, where the incidence of melanoma is extremely high. This was achieved through iterative development phases involving a multidisciplinary team of clinicians, end users, systems researchers and developers and informed by research evidence. Through the process, recommendations for interactive eHealth apps were put forward to maximize implementation success, that is, effectiveness and usability. These recommendations were:

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  Involve a multidisciplinary team in the development process

  
  
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  Engage users through managing complex messaging

  
  
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  Design for interactivity (i.e. user-friendliness).

Web applications for skeletal fragility care

While the principles of exercise for bone health are well understood, application of these principles in the context of self-management with consideration of an individual’s level of skeletal fragility, co-morbidities and fracture history is complex, again requiring complex and individualised messaging. A recent initiative from Osteoporosis Canada, in partnership with the University of Waterloo, sought to address this issue with the Too Fit To Fracture program. The program involved defining safe and appropriate exercise according to fracture risk based on published evidence and expert consensus and translation of evidence and real-world recommendations into user-focussed materials. The same development pathway has also been used for other eHealth applications, such as RA care . The partners developed patient-centred stories and practical examples of exercise programs according to fracture risk, using a series of YouTube clips delivered via the Osteoporosis Canada website ( http://www.osteoporosis.ca/osteoporosis-and-you/too-fit-to-fracture/video-series-on-exercise-and-osteoporosis ). The initiative was promoted globally in November 2015, where one video per day was posted for the month of November.

E-registries for persistent pain care

Stanford University has developed and implemented the Collaborative Health Outcomes Information Registry (CHOIR) system ( ) in response to the Institute of Medicine’s Report Relieving Pain in America . This open source, open standard, free data collection software was developed in partnership with cross-discipline scientists, clinical experts and the National Institutes of Health, which allows clinicians to obtain qualitative information from people with pain in a safe, secure and easy-to-use system. The obtained information is designed to inform the optimal treatment for each individual, for example, by providing summary charts about how a person responds to treatment over time. CHOIR has been integrated into the clinic using Internet-enabled mobile devices (e.g. iPads). At present, there are approximately 15,000 unique patients, 64,000 visits and 40,000 follow-up visits. In addition, at Stanford Medical Centre, CHOIR is used in clinical practice and research.

In Australia, the electronic Persistent Pain Outcomes Collaboration (ePPOC: http://ahsri.uow.edu.au/eppoc/index.html ) is a recent strategic implementation initiative of the Australian and New Zealand College of Anaesthetists, Faculty of Pain Medicine, which aligns with the National Pain Strategy . The first phase started in 2013, with further cross-sector development by the Faculty of Pain Medicine, the Australian Pain Society and the wider pain community. The implementation strategy uses a systemised approach for the electronic collection of a standard set of data items and assessment tools by specialist pain services throughout Australia and New Zealand to measure person-centred and system outcomes in response to treatment . De-identified data are analysed by ePPOC, with results provided to participating services every 6 months. Currently, data of over 6000 patients have been collected, describing demographic and clinical characteristics (e.g. the back was the most common painful site (43%)), along with information about care received. These data will inform a national benchmarking system for the pain sector, with a view to levering improved outcomes and best-practice interventions that are key components of MoCs. Data will also enable development of a coordinated approach to pain research in Australasia.

Telehealth for pain care

Telehealth to deliver pain care has been implemented using a variety of models, including store-and-forward, direct contact consultation, hub and spoke consultation and home-based models of service delivery . TelePain is an initiative developed and implemented in Washington State, Wyoming, Alaska, Montana and Idaho (USA), and uses video-, Internet- and telephone-conferencing technologies to bridge the gap in community needs for pain services . Using a cluster RCT of a telehealth-enhanced intervention, the comparative effectiveness (cost and health outcomes) of TelePain compared with usual care is currently being explored . Eaton and colleagues outline specific challenges in the implementation of TelePain (systems, clinician and patient, time and cost), highlighting the critical role of strong cross-sector engagement as a cornerstone of successful implementation, with these findings being consistent with recent recommendations . Similarly, a range of telephone- and Internet-delivered care models for people with OA pain are currently being explored through the Australian Centre for Health Exercise and Sports Medicine ( ).

The ‘how to do it’ of eHealth implementation, however, appears to have leapfrogged the ‘what to do’ regarding best evidence. The interpretation of evidence from current studies is complicated by clinical heterogeneity, different modes of telehealth (telephone versus visual communication) and variable outcomes (systems versus person-centred). A recent review of telehealth highlighted the need for more high-quality studies, which measure person-centred health outcomes and risk profiles, and which develop pain services to better align with patient needs. A related meta-analysis revealed an overall benefit of telehealth interventions over control conditions and equivalence with in-person interventions; however, some reviewed studies showed no benefit compared with control interventions . However, some of the reviewed studies found no benefit for telehealth over control conditions. Some methodological concerns among the examined research included poor research quality, small sample sizes, and the examination of telehealth pain interventions without proven efficacy for in-person treatment.