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Background: With the increasing penetration of digital mobile devices among adolescents, mobile texting messaging is emerging as a new channel for patient-clinician communication for this population. In particular, it can promote active communication between healthcare clinicians and adolescents with asthma. However, little is known about the content of the messages exchanged in medical encounters via mobile text messaging. Therefore, this study explored the content of text messaging between clinicians and adolescents with asthma. Materials and Methods: We collected a total of 2,953 text messages exchanged between 5 nurse case managers and 131 adolescents with asthma through a personal digital assistant. The text messages were coded using a scheme developed by adapting categories from the Roter Interaction Analysis System. Results: Nurse case managers sent more text messages (n=2,639) than adolescents with asthma. Most messages sent by nurse case managers were targeted messages (n =2,475) directed at all adolescents with asthma, whereas there were relatively few tailored messages (n =164) that were created personally for an individual adolescent. In addition, both targeted and tailored messages emphasized task-focused behaviors over socioemotional behaviors. Likewise, text messages (n =314) sent by adolescents also emphasized task-focused over socioemotional behaviors. Conclusions: Mobile texting messaging has the potential to play an important role in patient-clinician communication. It promotes not only active interaction, but also patient-centered communication with clinicians. In order to achieve this potential, healthcare clinicians may need to focus on socioemotional communication as well as task-oriented communication. [ABSTRACT FROM AUTHOR]

Background Healthcare reform in the United States is encouraging Federally Qualified Health Centers and other primary-care practices to integrate treatment for addiction and other behavioral health conditions into their practices. The potential of mobile health technologies to manage addiction and comorbidities such as HIV in these settings is substantial but largely untested. This paper describes a protocol to evaluate the implementation of an E-Health integrated communication technology delivered via mobile phones, called Seva, into primary-care settings. Seva is an evidence-based system of addiction treatment and recovery support for patients and real-time caseload monitoring for clinicians. Methods/Design Our implementation strategy uses three models of organizational change: the Program Planning Model to promote acceptance and sustainability, the NIATx quality improvement model to create a welcoming environment for change, and Rogers's diffusion of innovations research, which facilitates adaptations of innovations to maximize their adoption potential. We will implement Seva and conduct an intensive, mixed-methods assessment at three diverse Federally Qualified Healthcare Centers in the United States. Our non-concurrent multiple-baseline design includes three periods — pretest (ending in four months of implementation preparation), active Seva implementation, and maintenance — with implementation staggered at six-month intervals across sites. The first site will serve as a pilot clinic. We will track the timing of intervention elements and assess study outcomes within each dimension of the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework, including effects on clinicians, patients, and practices. Our mixedmethods approach will include quantitative (e.g., interrupted time-series analysis of treatment attendance, with clinics as the unit of analysis) and qualitative (e.g., staff interviews regarding adaptations to implementation protocol) methods, and assessment of implementation costs. Discussion If implementation is successful, the field will have a proven technology that helps Federally Qualified Health Centers and affiliated organizations provide addiction treatment and recovery support, as well as a proven strategy for implementing the technology. Seva also has the potential to improve core elements of addiction treatment, such as referral and treatment processes. A mobile technology for addiction treatment and accompanying implementation model could provide a cost-effective means to improve the lives of patients with drug and alcohol problems. Trial registration ClinicalTrials.gov (NCT01963234). [ABSTRACT FROM AUTHOR]

Universal access to health and medical information may foster a democratization of information and improve public health. According to a 1997 survey, 41% of households have a personal computer, and the use of the Internet for research, education, and entertainment is widespread. Access to health information can increase knowledge, improve emotional state, and may reduce health care costs. The provision of low-cost or loaned computers to the needy, with discounted access to online sources, may increase health knowledge and reduce health inequalities.

Purpose: Current medication-adherence predictive tools are based on patient medication-taking beliefs, but studying past behavior may now be a more explanatory and accessible method. This study will evaluate if past medication-refill behavior for a statin regimen is more predictive of medication adherence than patient medication-taking health beliefs. Patients and methods: This prospective longitudinal study was implemented in a national managed care plan in the United States. A group of 1433 statin patients were identified and followed for 6 months. Medication-taking health beliefs, collected from self-reported mail questionnaires, and past medication-refill behavior, using proportion of days covered (PDC), were collected prior to 6-month follow-up. Outcomes were measured using categorical PDC variable (of adherence, PDC < 85%, versus nonadherence, PDC < 85%), with model fit estimated using receiver operator characteristic analysis. Results: The area under the receiver operator characteristic curve for past behavior (Az = 0.78) was significantly greater (P < 0.05) than for patient health beliefs (Az = 0.69), indicating that past prescription-refill behavior is a better predictor of medication adherence than prospective health beliefs. Among health beliefs, the factor most related to medication adherence was behavioral intent (odds ratio, 5.12; 95% confidence interval, 1.84 to 15.06). The factor most strongly related to behavioral intent was impact of regimen on daily routine (odds ratio, 3.3; 95% confidence interval, 1.41 to 7.74). Conclusion: Electronic medical records and community health-information networks may make past prescription-refill rates more accessible and assist physicians with managing medicationregimen adherence. Health beliefs, however, may still play an important role in influencing medication-taking behaviors. [ABSTRACT FROM AUTHOR]

Background: Dissemination is a critical facet of implementing quality improvement in organizations. As a field, addiction treatment has produced effective interventions but disseminated them slowly and reached only a fraction of people needing treatment. This study investigates four methods of disseminating quality improvement (QI) to addiction treatment programs in the U.S. It is, to our knowledge, the largest study of organizational change ever conducted in healthcare. The trial seeks to determine the most cost-effective method of disseminating quality improvement in addiction treatment. Methods: The study is evaluating the costs and effectiveness of different QI approaches by randomizing 201 addiction-treatment programs to four interventions. Each intervention used a web-based learning kit plus monthly phone calls, coaching, face-to-face meetings, or the combination of all three. Effectiveness is defined as reducing waiting time (days between first contact and treatment), increasing program admissions, and increasing continuation in treatment. Opportunity costs will be estimated for the resources associated with providing the services. Outcomes: The study has three primary outcomes: waiting time, annual program admissions, and continuation in treatment. Secondary outcomes include: voluntary employee turnover, treatment completion, and operating margin. We are also seeking to understand the role of mediators, moderators, and other factors related to an organization's success in making changes. Analysis: We are fitting a mixed-effect regression model to each program's average monthly waiting time and continuation rates (based on aggregated client records), including terms to isolate state and intervention effects. Admissions to treatment are aggregated to a yearly level to compensate for seasonality. We will order the interventions by cost to compare them pair-wise to the lowest cost intervention (monthly phone calls). All randomized sites with outcome data will be included in the analysis, following the intent-to-treat principle. Organizational covariates in the analysis include program size, management score, and state. Discussion: The study offers seven recommendations for conducting a large-scale cluster-randomized trial: provide valuable services, have aims that are clear and important, seek powerful allies, understand the recruiting challenge, cultivate commitment, address turnover, and encourage rigor and flexibility. Trial Registration: ClinicalTrials. govNCT00934141 [ABSTRACT FROM AUTHOR]

Abstract: The Network for the Improvement of Addiction Treatment (NIATx) teaches participating treatment centers to use process improvement strategies. A cross-site evaluation monitored impacts on days between first contact and first treatment and percent of patients who started treatment and completed two, three and four units of care (i.e., one outpatient session, 1 day of intensive outpatient care, and 1 week of residential treatment). The analysis included 13 agencies that began participation in August 2003, submitted 10–15 months of data, and attempted improvements in outpatient (n =7), intensive outpatient (n =4) or residential treatment services (n =4) (two agencies provided data for two levels of care). Days to treatment declined 37% (from 19.6 to 12.4 days) across levels of care; the change was significant overall and for outpatient and intensive outpatient services. Significant overall improvement in retention in care was observed for the second unit of care (72–85%; 18% increase) and the third unit of care (62–73%; 17% increase); when level of care was assessed, a significant gain was found only for intensive outpatient services. Small incremental changes in treatment processes can lead to significant reductions in days to treatment and consistent gains in retention. [Copyright &y& Elsevier]

This article consolidates insights from 15 years of research examining how the medically underserved use and benefit from an eHealth program, the Comprehensive Health Enhancement Support System (CHESS). The authors outline results from early feasibility tests to determine if the underserved would use CHESS. Distinctive behaviors of underserved populations who have used CHESS are reported with a focus on how online health information and computer-mediated support groups are used. The article then reports on how the underserved benefit from using CHESS. Best practice recommendations for recruitment and training the underserved are offered, and implications for closing the digital divide are discussed. [ABSTRACT FROM AUTHOR]

This study compared the survey responses of 280 current and former adolescent smokers for what they perceived would he helpful (or what had helped) in quitting smoking. The survey was developed from focus groups and was structured using Prochaska and DiClementes Stages of Change health behavior framework. Results showd that former smokers and current smokers in the preparation stage of change shared beliefs about the importance of interpersonal support, those who were contemplating a quit decision warned about obstacles and internal issues, and current smokers not thinking about quitting focused on external rewards. The findings that significant differences exist based on the adolescent smokers Stage of Change imply that this framework can be appropriately applied to this context. [ABSTRACT FROM AUTHOR]

Objective. To test the effectiveness of a Bayesian model employing subjective probability estimates for predicting success and failure of health care improvement projects. Data Sources. Experts' subjective assessment data for model development and independent retrospective data on 221 healthcare improvement projects in the United States, Canada, and the Netherlands collected between 1996 and 2000 for validation. Methods. A panel of theoretical and practical experts and literature in organizational change were used to identify factors predicting the outcome of improvement efforts. A Bayesian model was developed to estimate probability of successful change using subjective estimates of likelihood ratios and prior odds elicited from the panel of experts. A subsequent retrospective empirical analysis of change efforts in 198 health care organizations was performed to validate the model. Logistic regression and ROC analysis were used to evaluate the model's performance using three alternative definitions of success. Data Collection. For the model development, experts' subjective assessments were elicited using an integrative group process. For the validation study, a staff person intimately involved in each improvement project responded to a written survey asking questions about model factors and project outcomes. Results. Logistic regression chi-square statistics and areas under the ROC curve demonstrated a high level of model performance in predicting success. Chi-square statistics were significant at the 0.001 level and areas under the ROC curve were greater than 0.84. Conclusions. A subjective Bayesian model was effective in predicting the outcome of actual improvement projects. Additional prospective evaluations as well as testing the impact of this model as an intervention are warranted. [ABSTRACT FROM AUTHOR]

The AIDS epidemic has challenged every aspect of the health services delivery system from prevention activities and programs to nursing home care. Computer technology provides a strategy for meeting the needs of both people at risk as well as those infected with HIV. CHESS (Comprehensive Health Enhancement Support System) is an integrated decision support system that provides multi-dimensional theory-based resources to people infected with HIV and to people at risk of contracting the infection. CHESS provides users with anonymous, current, nonjudgmental, easily accessible information, decision support, referral, and social support. T [ABSTRACT FROM AUTHOR]

Presents an editorial on the evaluation of ehealth systems and services. Need for ehealth developers to first evaluate the users' needs, then the product's risks and benefits, then its feasibility and its acceptability to the user; Way that web sites should include content that is of high quality and useful to the user; Cost implications of ehealth programs; View that evaluations need to determine how people use various ehealth features and how such use relates to health outcomes.

Abstract: Purpose: To examine how psychosocial variables predicted use of an online health consultation service among low-income breast cancer patients and in turn how using this service affected these same psychosocial outcomes. Method: This retrospective study included 231 recently diagnosed, low-income (at or below 250% of the federal poverty level) breast cancer patients provided a free computer with 16 weeks of access to the Internet-based ‘Ask an Expert’ service offered as part of the Comprehensive Health Enhancement Support System (CHESS) “Living with Breast Cancer” program. The use activity included a total of 502 messages submitted to the online health consultation service. The data included five psychosocial variables: information seeking, social support, health self efficacy, participation in health care, and doctor–patient relationship, were collected at both the pre-test and 16-week post-test after using the service. Correlation tests were conducted to examine the relationship between pre- and post-test, and use activity. A multiple regression model was formed for each of five psychosocial variables to examine how use activity of the consultation service was associated with various psychosocial measurements. Results: In total, 865 distinct consulting queries from 502 messages were identified as measurement of patients’ use activities (3.74 consulting queries per participant). Use activity had significant negative relationships with pre-test scores across all five psychosocial variables. The regression models found significant positive main effects (use activity) associated with three of these psychosocial variables: health self efficacy, participation in health care and doctor–patient relationship. Use activity of the online consultation service did not have significant relationships with the dependent variables of information seeking and perceived social support. Conclusion: Low-income breast cancer patients sought out information from an online cancer information expert. Patients with more negative perceptions at pre-test tended to use the service more. Greater use of the service was associated with improvement in patients’ perception of health self-efficacy, participation in health care and doctor–patient relationship. Moreover, use of online health consultation appears to level the differences, narrowing the gaps between those who were worse and better off at pre-test. These findings suggest that online health consultation can serve as an effective complement to other resources, which help low-income, breast cancer patients feel more confident to participate more actively in their health care, become more actively involved in making decisions about their treatments and enhance the relationship with their doctors. [Copyright &y& Elsevier]

Objectives: To determine the effects of online narrative and didactic information on breast cancer patients’ healthcare participation and the interaction effects of race. Methods: Sample: 353 breast cancer patients (111 African Americans) using an eHealth program with narratives (audiovisual and text) and didactic information (text only). Measures: healthcare participation scale (0, 4 months), online information use. Analyses: hierarchical regression. Results: Narrative (β =0.123, p <0.01) and didactic (β =0.104, p <0.05) information use had independent and positive effects on healthcare participation. Effects of both were significantly greater for African Americans. Conclusions: Findings are consistent with and advance prior research on online learning processes and outcomes for breast cancer patients: (1) benefits accrue with using a variety of online learning tools; (2) African Americans use and benefit more from online narrative and didactic information than do Caucasians. Practice implications: eHealth programs should provide both didactic and narrative information—especially for African Americans and might consider making greater use of interactive and audiovisual formats. As patients increasingly use of the web for cancer information, clinicians should provide lists of web high quality resources that provide both narrative and didactic information. [Copyright &y& Elsevier]

Abstract: Objective: To examine how the pre-existing doctor–patient relationship predicts conceptually distinct service use within an Interactive Cancer Communication System (ICCS) for underserved women with breast cancer and in turn how service utilization influences the doctor–patient relationship. Methods: Study sample included 231 recently diagnosed, lower income breast cancer patients. Participants were provided a free computer, Internet access and training in how to use an ICCS called the Comprehensive Health Enhancement Support System (CHESS) “Living with Breast Cancer” program. Survey data was collected at pre-test and 4-months after using the system, and use data about how women used the system was also collected. Results: The only statistically significant predictor of service use was that patients with a more negative appraisal about the doctor–patient relationship used the Ask an Expert service more frequently, and there were trends toward a more negative appraisal of the doctor–patient relationship being associated with higher use of Information and Interactive services. Conversely, there was a trend toward a more positive appraisal predicting higher use of the Discussion Group service. In terms of statistically significant effects, more frequent utilization of Information services was associated with a more positive appraisal of the doctor relationship. Conclusion: While a more negative perception of the doctor–patient relationships at pre-test was associated with higher use of most of the conceptually distinct services within this ICCS, use of the Information services was associated with having a more positive appraisal of the doctor–patient relationship at post-test suggesting that high-quality information on the Internet can serve to improve patients’ satisfaction with their doctor. [Copyright &y& Elsevier]