JMIR Publications

ABSTRACT

Background:

Cardiac rehabilitation (CR) is an evidence-based intervention that improves event-free survival in cardiac patients; yet, fewer than 30% of all eligible patients utilize CR in the United States. Traditionally, CR is delivered in clinic-based settings; a delivery model that has faced persistent implementation barriers. Accordingly, innovative, nontraditional program designs and strategies are needed to support the widespread uptake of CR programs.

Objective:

The primary objective of this study was to demonstrate how user-centered design (UCD) and implementation science (ImS) principles can be integrated into the early-stage development of nontraditional CR interventions, with the goal to improve CR uptake in real-world clinical settings.

Methods:

As part of a New York Presbyterian Hospital (NYPH) quality improvement initiative (March 2020-February 2022), we combined UCD and ImS principles to design a novel telehealth-enhanced hybrid (home and clinic-based) CR (THCR) program. We designed the THCR program using an iterative 3 step UCD process informed by the Theoretical Domains Framework and Consolidated Framework for Implementation Research to: 1) identify user and contextual barriers to CR uptake (stakeholder interviews), 2) design an intervention prototype (design workshops and journey mapping), and 3) refine the prototype (usability testing).

Results:

Step 1: Semi-structured interviews with stakeholders (n=9) at 3 geographically diverse academic medical centers revealed behavioral (e.g., self-efficacy, knowledge) and contextual (e.g., social distancing guidelines, physical space, staffing, reimbursement) barriers to uptake. Step 2: Design workshops (n=20) and journey-mapping sessions (n=3) with multi-disciplinary NYPH stakeholders (e.g., digital health team, CR clinicians, creative director) yielded a THCR prototype that leveraged NYPH’s investment in their remote patient monitoring (RPM) platform to optimize feasibility of home-based CR sessions. Step 3: Usability testing with CR clinicians (n=2) administering and CR patients (n=3) participating in home-based sessions revealed usability challenges (e.g., RPM devices/exercise equipment usability; Wi-Fi/Bluetooth connectivity/syncing; patient safety/knowledge and protocol flexibility). Design workshops (n=24) and journey-mapping sessions (n=3) yielded design solutions (e.g., onboarding sessions, safety surveys, fully supervised remote sessions) and a refined THCR prototype.

Conclusions:

Combining UCD and ImS methods while engaging multi-disciplinary stakeholders in an iterative process yielded a theory-informed telehealth-enhanced hybrid CR program targeting user and contextual barriers to real-world CR implementation. We provide a detailed summary of the process, and guidance for incorporating UCD and ImS methods in early-stage intervention development. THCR may shrink the evidence-to-practice gap in CR implementation. A future hybrid type I effectiveness-implementation trial will determine its feasibility, acceptability, and effectiveness.