1. HeartCare II: CHF Patricia Flatley Brennan, RN, Ph.D., FAAN Laura J. Burke, R.N., Ph.D., FAAN Pascale Carayon, Ph.D. Ben Tzion Karsh, Ph.D. Margaret Sebern, RN, Ph.D. Michael J. Smith, Ph.D. Roger Brown, Ph.D.

2. Who Are the Study Team Members? (Right to Left) Patricia Brennan, RN, PhD, FAAN 15 years exp. evaluating impact of computer network-delivered services on clinical and functional outcomes of ill persons and families Laura Burke, RN, PhD, FAAN 11 years exp. as cardiac CNS and 11 years exp. as a health systems researcher for the Aurora system Marge Sebern, RN, PhD 7 years exp. in nursing education, 20 years exp. in home health care as a researcher, administrator, and rehabilitation CNS

3. Who Are the Study Team Members? (Left to Right, Top to Bottom) Pascale Carayon, PhD BenTzion Karsh, PhD Michael J. Smith, PhD Experts in studying human and organizational impact of information technology in health care and offices Roger Brown, PhD Expert statistician

4. Study Background: 1985-1992, Brennan, ComputerLink Pre-WWW computer networks provided patient access to: Information Communication Nurse-to-patient Patient-to-patient Decision Support Patient populations: Persons living with AIDS (n=60) Caregivers of Alzheimer’s Disease patients (n=102) Outcomes: Reduced social isolation Decreased depression Improved confidence in decision-making Caregivers study Demonstrated that elders w/ complex health problems can/will use computers in the home

5. Study Background: HeartCare I-CABG Recovery Used WWW, Web TVs Provided sequenced, tailored information and communication utilities to pts post CABG 6-month experiment Usual care (n=32), audiotape care (n=53), HeartCare (n=54) 2,613 accesses to HeartCare Accesses decreased over time Most accesses during first 7 days Four patterns of use identified Pts. w/ access to web-based coaching & information resources Recovered faster Fewer symptoms Less bothered by symptoms Less depression Less negative mood state

6. Study Aims 1. Conduct a work analysis of the VNA nurses’ practice using industrial engineering techniques to: Identify aspects of the practice that could be enhanced by technology Better characterize aspects of the clinical situation likely to be altered by the introduction of consumer health informatics tools 2. Design a suite of electronic services (communication, personal health records, educational materials) that support Aurora’s evidence-based CHF protocols for VNA.

7. Study Aims 3. Plan with VNA nurses, using local practical knowledge, how to implement Technology- Enhanced Practice (TEP). 4. Conduct a randomized field experiment of 400 patients assigned to 20 care teams.

8. Study Design & Methods: Phase I (Aspect1) – Work Analysis/TEP Design Patient Information Will be informed during scheduling of first visit that nurse may have “ride-along” visitor Will be told purpose and asked if visitor can come into home Can opt to not have visitor come into home Nurse Information Informational meetings being scheduled for August 10 volunteers in Metro and/or South needed for “ride-along” observation Will be asked questions for clarification Data will be collected on Job Analysis Form Data will be de-identified and kept confidential Paid time from VNA

9. Study Design & Methods: Phase I (Aspect 2) – Work Analysis/TEP Design Identification of Care Teams from Metro/South Teams randomly assigned to TEP or control group Design of TEP 20-30 TEP care team nurses included Series of design activities led by industrial engineers/ nurses via feedback sessions Create TEP by integrating Aurora CHF care management tools with consumer health informatics tools Paid time from VNA

10. Winona Health Online (using IQ Health): An Example of Consumer Health Information

13. Study Design & Methods: Phase I(3) – Work Analysis/TEP Design Nurse Usability Testing (1) 3 nurse volunteers from TEP care teams selected by research team and VNA management, based on ability to provide thoughtful critique of system See demo and use HeartCare II: CHF software for 30 minutes Complete QUIS survey on computer usage, interviews Paid hourly wage by grant Based on comments, TEP care team materials (including CHF care management materials) will be revised.

14. Study Design & Methods: Phase I(3) – Work Analysis/TEP Design Nurse Usability Testing (2) 3 different nurse volunteers from TEP care teams selected by research team and VNA management, based on ability to provide thoughtful critique of system See demo and use HeartCare II: CHF software for 30 minutes Complete QUIS survey on computer usage, interviews Paid hourly wage by grant Patient Usability Testing (2) 3 patients solicited from caseloads of TEP nurse volunteers, based on ability to provide thoughtful critique of system See demo and use HeartCare II: CHF software for 30 minutes Complete QUIS survey on computer usage, interviews Paid time $10/hour x 2 hours from grant

15. Study Design & Methods: Phase I (Aspect 4) – Work Analysis/TEP Design HeartCare II: CHF Training Module and Refresher Training Module Developed Research team members Marge Sebern, RN, PhD Gail Casper, RN, PhD Laura Burke, RN, PhD Consultants: Joann Paulsen, RN Mary Hook, RN Al Klewin, RPh Mike Jaeger, MD Mike Gorzynski, MD CHF Care Management Team Nurse Training Module Development 5 volunteers selected by research team and VNA administration based on ability to provide thoughtful critique Complete training Participate in interviews Paid hourly wage by grant

16. Study Design & Methods: Phase I (Aspect 5) – Work Analysis/TEP Design HeartCare II: CHF Training Module Face-to-face training All nurses on TEP care teams will complete training Paid time by VNA HeartCareII: CHF Refresher Training Module Web-based training Paid time by VNA If nurses choose to not participate in TEP care teams, VNA management will make every effort to transfer to a position delivering standard of care.

17. Study Design & Methods: Phase 2 (Aspect 6) – Work Analysis/TEP Design Randomized Field Experiment 10 TEP care teams, 200 patients (20 patients per care team) 10 standard care teams, 200 patients (20 patients per care team) 18 months allowed for subject recruitment Each patient is enrolled for 6 months Patients receive care according to care team assignment, but can decline study participation Eligibility Criteria Primary or secondary diagnosis of CHF, admitted to VNA service Clinically stable Able to read, speak, write English Live within 100 mile radius of Milwaukee Have a working phone line OASIS Cognitive Status (M0560) “alert or requires some prompting” OASIS Vision Status (M0390) “normal vision” Does not require continuous in- home professional care

18. Study Design & Methods: Phase 2 (Aspect 6) – Work Analysis/TEP Design Nurses determine care practices #, frequency of visits Involvement of other team members Patient provided with computer access to HeartCare II: CHF Patient can keep technology at end of study, but have to pay for own ISP support after study Computers can be removed at our cost if not wanted to keep Patients on VNA service for usual time, but in study for 6 mo Patients receive $60 in cash at the end of the 6 months

19. Patient Measurement Plan & Timing Base - line Week 1 Week 4 Week 8 or DC Wee k 12 Week 24 About You (Demographic Data) X Self-Management of CHF XXXXXX Clinical Status XXXXX Use of Health Care Services XXXXX Quality of Life XXXXX Satisfaction with Care XXXX QUIS (Software Evaluation Survey) XXXXX Information Needs Assessment X Technology Assessment X

20. So What Does this Mean for Managers? Support overall project discussions at staff meetings Encourage staff to volunteer for Design/Testing opportunities Be available to answer questions as organizational systems are put into place

21. So What Does this Mean for Staff? Opportunity to design technology-enhanced nursing practice Opportunity to test interventions for effectiveness Opportunity to improve patient outcomes

22. Questions?