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CIN: Computers, Informatics, Nursing:
doi: 10.1097/CIN.0000000000000066
Feature Article

The Feasibility of Using Technology to Enhance the Transition of Palliative Care for Rural Patients


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Author Information

Author Affiliations: Department of Nursing (Drs Holland, Vanderboom, and Dose), College of Medicine (Drs Holland, Dose, Ingram, and Borkenhagen), and Palliative Care Consulting Service (Mss Borkenhagen and Skadahl), Mayo Clinic (Mr Pacyna and Ms Austin), Rochester, MN; and Professor of Nursing (Ms Bowles), School of Nursing, University of Pennsylvania, Philadelphia.

Funding for the study was provided by the Mayo Clinic Small Grants Program and the Nursing Research Review Committee.

The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article.

Corresponding author: Diane E. Holland, PhD, RN, Department of Nursing, College of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (

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Palliative care services for patients with life-limiting conditions enhance their quality of life. Most palliative care services, however, are located in hospitals with limited transitional care for patients who live in distant locations. The long-term goal of this program of research is to use existing technology for virtual visits to provide transitional care for patients initially hospitalized in an urban setting by a nurse practitioner located closer to patients’ homes in distant, rural settings. The purpose of this proof-of-concept study was to determine the resources needed to use the system (efficiency) and the quality of the audio and visual components (effectiveness) to conduct virtual visits between a clinician at an academic center and community-dwelling adults living in rural locations. Guided by the Technology Acceptance Model, a mixed-methods field design was used. Because of the burden of testing technology with patients with life-limiting conditions, the sample included eight healthy adults. Participant satisfaction and perceptions of the ease of using the technology were also measured. Virtual visits were conducted using a 3G-enabled Apple iPad, cellular phone data service, and a Web-based video conference service. Participants and clinicians perceived the technology as easy to use. Observations revealed the importance of the visual cues provided by the technology to enhance communication, engagement, and satisfaction. Findings from this study will inform a subsequent study of technology-enhanced transitional care with palliative care patients.

Palliative care (PC) services for patients with life-limiting illness have increased by 148% in the last 10 years1,2; however, the majority of PC services are located in hospitals with few mechanisms to transition PC for patients who live in distant, rural locations.3,4 Without a structure to coordinate the transition of complex care from hospital to home, discharge plans often fall apart. Poorly managed care transitions resulting in communication breakdowns and medical errors are disruptive to patients and families and are costly to the healthcare system.5 Health information technology (health IT) offers a possible solution to transition complex care by bridging geographical distances between patients and care teams.

The Transitional Care Model (TCM) is a care transition delivery model that has consistently demonstrated improved quality and reductions in hospital readmissions and healthcare costs,6–9 improved satisfaction with care, and improved quality of life.6 The TCM provides comprehensive in-hospital planning and home follow-up for chronically ill, high-risk older adults hospitalized for common medical or surgical conditions through an advanced practice nurse serving as the coordinator of care to ensure consistency across the entire episode of care.10 Unfortunately, the TCM presumes a geographic proximity of hospital to home where face-to-face interactions by a single advanced practice nurse across settings are physically possible. This is not a viable option for PC patients who are discharged from the hospital and return home to distant, rural locations. Health IT has been successfully used in home healthcare and end-of-life (hospice) care,11–15 suggesting that the use of technology may be a possible solution for transitioning PC across distances.

The use of technology to provide healthcare at a distance has been described as the principal way to balance the differences in resource availability between rural and urban areas.16 Technology minimizes logistical barriers and provides a way for frequent and targeted contact to address patient concerns. Patients living in rural locations report arduous travel, communication problems, difficulty obtaining medications and supplies, and ongoing isolation.14 In addition, technology with visual capabilities provides cues to understanding emotional states manifest in facial expressions, posture, or eye gaze; it allows for physical assessment; it is cost-effective; and it has high patient and clinician satisfaction.12,14,17,18

Prior to enrolling patients with life-limiting conditions, we first wanted to ensure the efficiency and effectiveness of the virtual visits. This is a necessary step to provide evidence of the resources needed and the quality of the audio and visual components of the virtual visits before providing transitional care for PC patients who are transferring from hospital to home. Healthcare inequities due to geographical factors are more pronounced at end of life, making provision and evaluation of health services that support PC in rural settings of critical importance.19

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Health Information Technology

The increasing use of technology and communication systems to provide healthcare at a distance (health IT) has led to the development of more user-friendly technologies resulting in lower costs.20 Video conferencing adds dimensions to caring beyond voice-only communication including increased patient-nurse rapport and partnership, support for patient self-management skills, and preparation for clinic visits.12 A recent Cochrane review indicated that since 1998 interactive health communications using in-home video to manage care of chronically ill, high-risk patients had positive effects on patient knowledge, social support, and clinical outcomes.18,21 Communication using home video has been well received and resulted in fewer hospital and outpatient visits for the elderly and their caregivers.21 While there are many telehealth initiatives for rural health populations,22–25 the use of virtual visits for providing transitional care across distances has not been tested. In addition, virtual interactions among other patient populations provided a strong foundation for the development and eventual use of health IT for PC patients.18,20,26

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The long-term goal of this program of research is to use existing technology for virtual visits to provide continuity of care for patients with life-limiting conditions during the transition from a hospitalization in an urban setting to homes in distant, rural settings. The purpose of this proof-of-concept study was to determine the resources needed and the quality of the audio and visual components to conduct virtual visits between a clinician located at an urban academic center and community-dwelling adults living in rural locations. The study aim was to determine efficiency and effectiveness of the technology. Participant satisfaction and perceptions of the ease of using the technology were also measured. This study will inform a subsequent study of technology-enhanced transitional care with PC patients in rural locations.

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Conceptual Framework

The Technology Acceptance Model (TAM) guided the study. The foundation of the TAM is a theory of human behavior from social psychology, which has been tested and used to represent theoretical understanding about information system usage and acceptance behaviors.27 The TAM hypothesizes that usefulness and ease of use are relevant to system acceptance behaviors.

Usefulness is defined in terms of the intended users of the system, the tasks to be performed, and the characteristics of the environment in which it will be used.27 Measuring usefulness includes (1) efficiency defined as the resources needed to use the system, (2) effectiveness defined as the quality of the audio and visual components, and (3) user satisfaction with the system. Usefulness of a system must be viewed within the context in which the system is used and its appropriateness to that context. Perceived ease of use is the “degree to which a person believes that using a system would be free of effort.”27 The focus of this proof-of-concept study was on efficiency (resources needed to use the system) and effectiveness (the quality of the audio and visual components) of the technology to connect clinicians in academic medical centers with individuals in their homes in distant, rural settings. User satisfaction and perceived ease of use were also measured.

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A mixed-methods field study design was used in this feasibility study. Qualitative analysis was the primary method used, with quantitative data informing the qualitative analysis. We incorporated a user-centered, multiple step approach to evaluate existing, secure (HIPAA compliant) technology to ensure the best fit with adults living in distant, rural settings and clinicians in academic medical centers.

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The population of interest is PC patients. However, healthy, community-dwelling older adults (aged 55+ years) were participants in this proof-of-concept study because of the burden of testing technology with patients with life-limiting conditions. Eight participants were identified by study team members through a purposive sampling strategy. Four older adults living near an urban medical center pretended to be hospitalized in the urban medical center. Four additional older adult participants living in rural areas pretended to receive transitional PC in their homes. The rural participants lived in small communities at least 45 miles from the community hospital. They participated in virtual visits with two nurse practitioner (NP) study staff who were also members of inpatient PC consulting services.

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The study was conducted in a large health system located in the upper Midwest. Sequential steps in the study required the use of a laboratory setting located in the urban medical center, home settings in rural areas, and usual NP work settings in an urban medical center and a community hospital (patient hospital rooms and an office). One NP was located in the urban medical center, and the other NP was located in the rural, community hospital.

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Study Procedures

With the assistance of a contracted third-party technology company, we identified, purchased, and configured devices and services from existing communication technology solutions to provide a standardized medium for the virtual visits. The technology options were chosen after careful consideration of security (HIPAA compliant), ease of use, cost and ease of setup based on the prior use of one of the investigators (K.H.B.) in a different study population. The technology company was experienced in the successful implementation of information technology applications in research and was responsible for the video service subscription, configuring the appropriate hardware, ensuring security and connectivity based on the participants’ geographic locations, troubleshooting, and providing technical support to the clinicians and participants during the study.

Our final hardware/software configuration was composed of three main components: (1) hardware consisting of a 3G-enabled Apple iPad (iPad; Apple, Cupertino, CA) for patients and the NP’s office computer equipped with a webcam and microphone, (2) activated cellular phone data service provided to the mock patient participants for the duration of the study, and (3) a HIPAA-compliant Web-based video conference service and a secure scheduling application.

The decision to use 3G-enabled Apple iPads equipped with cellular phone data service was made based on the limited communication technology options in the communities where the rural participants lived and the wide variety of potential technological services and paraphernalia configurations we could find in participant homes. The iPad was recommended by our technology consultant as it was the preferred hardware by participants in similar studies. The standard iPad also comes with a built-in user-facing video camera that effectively captures the user’s visage. The NP’s office computer was equipped with a standard webcam set on top of the computer monitor to collect video and audio. Setting up the webcam was a simple process, typical of standard “plug and play” devices designed to be widely compatible with major computer operating systems and system versions.

With our configuration, the iPads connected directly to local cellular phone data towers providing data service with enough bandwidth to support video transmission for the virtual visits/video sessions. The cellular phone service provider we selected was the only vendor at the time that provided sufficient coverage to the rural geographical areas within the study. In the event that the quality of reception was low (eg, because of distance from the cell tower), we were also able to provide an additional stand-alone device called a “gain antennae,” which was hoped would more efficiently capture the local data service and amplify the signal within the home.

The HIPAA-compliant video conference service was a Web-based video conferencing solution recommended by our contracted technology consultant as a dependable, encrypted video conferencing medium with document sharing, team discussion, and recorded session capabilities. This video conferencing service provided a proprietary iPad application with an intuitive design that enabled patients to engage in the video visits. The video conferencing service was integrated into a customized scheduling application. The NPs and study staff were assigned individual user names and passwords for two separate, secure Web portal systems of the third-party technology company. One set of user names and passwords accessed a calendar where participant scheduling information was maintained and virtual conference rooms (“My rooms”) were assigned to NPs and participants. The portal produced automated reminder calls to participants 1 day and again 1 hour before virtual visits were scheduled, prompting them to be ready with their iPad in hand and the video conferencing application running, while NPs received automated reminder e-mails reminding them to be ready to initiate the virtual visit at the established time. At the appointment start time, the NP would initiate the video call to the participant’s device, and the connection would be established. The video service subscription utilized in the study allowed the NP to participate in the virtual sessions using her desktop office computer.

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The study was implemented in three steps. A summary of study steps is provided in Table 1. Step 1 included initial technological training of the NPs in a healthy aging and independent living (HAIL) laboratory. The HAIL laboratory is a place for designing, prototyping, and piloting new services and technologies. The laboratory has room for focus groups and observations, a mock-up apartment for in-laboratory studies, and rooms for other experiments.28 After the training session, the NPs practiced virtual visits/video sessions in their usual work settings to communicate with each other across geographically distant sites using an iPad and a desktop office computer with a webcam and microphone two times per week for 2 weeks to determine how to incorporate the virtual visits into their daily workflows. A study team member role played a hospitalized patient during these visits.

Table 1
Table 1
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Step 2 was conducted to imitate virtual visits between the study NPs and hospitalized PC patients. After providing informed verbal consent, four healthy community-dwelling older adults pretended to be hospitalized patients. Each older adult and the NPs participated in a virtual visit/video session to imitate development of an individualized transition plan for a hospitalized patient planning their return home. Adult participants and one NP were located in the HAIL laboratory and used an iPad to communicate with the second NP using a webcam and microphone on her desktop computer in her usual office space at the distant community hospital. These visits were designed to last up to 30 minutes.

Step 3 involved virtual visits/video sessions between the community hospital NP at her desktop computer with the webcam and microphone in her office and four adult participants using iPads in their rural homes. A training session for the participants on the use of the iPads was conducted in their homes by a member of the study team. Written instructions were also provided. After the training, virtual visits/video sessions were conducted between the NP and participants twice weekly for 1 week, then weekly for 2 weeks. These visits were expected to last approximately 30 minutes.

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Variables and Measures

Usefulness (resources needed, the quality of the audio and visual components, and satisfaction) (Study Aim 1) was measured by observations, field notes, and semistructured interviews. Virtual visits between the mock patients and NPs were observed by trained nonparticipant study staff during each step of the study using observation guides and field notes. Participant perceptions of ease of use were measured by observations, field notes, interview, and the Perceived Ease of Use (PEU) questionnaire. A brief interview regarding participants’ perceptions of the experience was conducted at the completion of the study by all participants in the video sessions (mock patients and the NPs). Interviews were audio recorded and transcribed verbatim.

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Observations, Field Notes, and Interviews

Observation is an ongoing dynamic activity that is more likely than interviews to provide evidence for process29; observation provides in-depth “in the moment” data.30 Nonparticipant observers used reactive observation, in which the setting was controlled and participants were aware they were being observed.31 Observers gathered data through the use of a semistructured observation guide in the laboratory, clinical, and home settings where the virtual visits/video sessions took place.

Observers also kept detailed narrative field notes to provide additional context and detail and to serve as a reflective diary to capture the observer’s thoughts and expressions of how life experiences and perceptions might influence unintentional filtering of the observation. The overall goal of the observations was to evaluate usefulness and the clinicians’ and patients’ perceptions of ease of using the technology by capturing context and processes to illustrate the numerous facets of the virtual visit.32

Semistructured interviews involving two open-ended questions about the use of the technology were asked of the participants immediately after their final video session. Interviews were audio recorded and transcribed verbatim.

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Perceived Ease of Use

Ease of use was evaluated in the observations and interviews described above and also using the PEU questionnaire.33–35 The PEU is an 8-item questionnaire rated on a 5-point Likert scale (strongly disagree, disagree, neutral, agree, strongly agree). The questionnaire has been evaluated for convergent, discriminant and factor validity and internal consistency (Cronbach’s α reliability = .94).27,33–35

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The analysis incorporated the qualitative and quantitative data collected during each step of the study. Data from observations and field notes were transcribed verbatim and analyzed using NVivo 8 software (QSR International, Doncaster, Victoria, Australia) by the research team, guided by an experienced qualitative methods researcher. Descriptive content analysis techniques36 guided the analysis. Data from the semistructured interviews were audio recorded, transcribed, and merged with data from the questionnaire with the assistance of an experienced qualitative methods researcher. Counts and proportions were used to describe the sample and the data from the PEU questionnaire. Credibility was achieved through triangulation of data sources (comparing observations, interviews, and quantitative data) and by using multiple analysts and achieving consensus throughout data collection and analysis.37

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A total of eight individuals participated in the study as mock patients. Six of the participants were female (75%). All were white, college educated, and older than 50 years. All participants used a computer at home (e-mail, Internet searches, create documents). Two of the eight participants used Skype to interact with their children.

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Resources Needed

Resources needed to use the system were categorized as (1) hardware, (2) connectivity (cellular phone service/ wireless Internet), and (3) Web-based video conference service and scheduling.

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The 3G-enabled iPad device allowed us to provide participants with standardized virtual visit technology without disturbing their personal Internet subscriptions and devices and without relying upon and modifying participants’ computer hardware and software. In addition, the iPads were lightweight, compact, easy to store, and portable. None of the participants had iPads, nor indicated they had used them previously. The only challenge in using the webcam and microphone on the NP’s desktop computer in her usual office space was the need for the NP to assess and adjust the camera angle and/or the NP’s proximity to the camera at the start of each video session to ensure that the patient participant could adequately see the NP.

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Participants had limited or no knowledge of what hardware, software, and Internet configurations they had in place in their own homes. They simply knew that “it worked.” Using participant’s own technology for the study would have required invasive configuration of the participant’s hardware, software, and Internet service. Communication and configuration arrangements with the participants’ Internet provider would have required that the participant extend account authorization to an IT-proficient member of our research team who would have made administrative adjustments to the Internet subscription as a proxy of the study participant. For these reasons, providing both hardware (iPad) and data services (via cell phone company data subscription) was deemed to be the most efficient, noninvasive way to equip participants with the needed technology for the virtual visits.

During our scheduled observations, it was revealed that only one of the homes had been previously configured to support use of Wi-Fi. Using participants’ existing technology, although not impossible, would have required knowledgeable IT support to change individual hardware and software configurations, as well as to communicate with the local Internet provider, and seemed too intrusive for the purposes of the study. For example, we recognized that two of the participants subscribed to Internet services through a local cable company. While cable Internet service was available in three of the participants’ homes, only one home had an established wireless network.

We attempted to provide a preconfigured wireless router that would establish a secured wireless network using the incoming cable Internet signal. We were successful at creating and connecting to the wireless network, but unsuccessful at channeling the incoming cable Internet signal through the network. The failure of this attempt was likely due to a security stop imposed by the local cable Internet service provider limiting the Internet signal provision to a “hard-wire” configuration. We assume this stop could have been removed if requested by the subscriber (participant); however, doing so was not possible in the short time frame of the study. In both instances, the existing hardware and software configuration in the participant homes had been established by a technician from the cable company.

A wireless network had already been established by one of our participants. In cases like this, the iPad could be easily enabled to “join” the participant’s wireless network, and configuration of the participant’s existing hardware and software would not be needed in order to utilize the participant’s existing data service. However, configuration of participant hardware and software was not deemed to be feasible. Configuration presented the risk of inadvertently disabling the participant’s services, requiring intervention by the local Internet service provider for a fee.

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The virtual visit video software was downloaded to the NP’s office PC, and the video application was preinstalled on each participant’s iPad. Individual user names and passwords were auto populated upon each participant log-in. The virtual visits were initiated by the NP logging onto a secure Web portal, which required the second set of individual user names and passwords. The NP user needed to go through a number of steps to use the Web-based conference service. Options/instructions provided were not always intuitive to participants. In addition, if any length of time had transpired between encounters, access codes and passwords needed to be reset. Occasionally, the browser needed to be restarted, or users needed to wait for the system to become available if the entire system was down. The document sharing, team discussion, and recorded session capabilities were not features of interest for the purposes of our study.

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Quality of the Audio and Visual Components

In Step 1, practice sessions occurred between NPs at both hospitals (institutional Wi-Fi at both locations). Most of the identified problems were with audio quality (eg, audible static buzz, echoing sound). There were a few, infrequent occurrences of freeze framing. These issues were resolved by changing locations (switching rooms throughout the hospital) to seek better reception. Phone calls and text messaging were used to work out glitches. In Step 2, when mock patients participated from the HAIL laboratory connecting to the NP in her community hospital office (institutional Wi-Fi at both locations), all four virtual visits proceeded smoothly. Audio and visual quality was satisfactory. In Step 3, when the community hospital NP connected with mock patients in their rural homes (institutional Wi-Fi at the hospital, cellular data service in the patient’s home), some problems emerged that interfered with the audio and video quality of the virtual visits. When weather conditions included high winds, the signal seemed to be very intermittent and choppy. The picture itself was clear, but there was frequent freeze framing and lag time in the audio (see Table 2 for narrative comments). Participants who owned home computers and regularly used Skype related they had similar experiences of poor visual/sound quality during inclement weather conditions in the past. On days with little wind, both the visual quality and audio quality were reported as good, allowing them uninterrupted Skype sessions with family members.

Table 2
Table 2
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User Satisfaction

User satisfaction data were gathered as part of the postencounter interviews. Community-dwelling adults and NPs were both generally eager to learn about the technology and engage in these practice sessions. The NPs involved had varying levels of prior experience with technology such as use of video conferencing. Once initial educational and practice sessions were completed, the NP became more comfortable with using it, but verbalized a preference for an in-person encounter first to establish the client-provider relationship before embarking on the virtual visits.

All community-dwelling adult participants were quite enthusiastic about the encounter and pleased overall with the quality of the interaction and technology. They endorsed the additional benefits of using both visual and audio and were generally eager to learn about the technology and engage in these practice sessions.

The NPs were engaged in all aspects of the technology from education to troubleshooting, letting the community-dwelling adult participants know if they were slipping out of sight, and slowing the pace of the conversation if necessary during the roughest of connection quality sessions. Their attitudes remained positive, professional, and encouraging throughout the encounters. They could envision enhancements to the virtual sessions in the home setting such as physical and environmental assessments.

The NPs were also queried about the fit of these virtual visits within the context of their other clinical duties. Generally, they were both able to make this work, but during their participation in the study, they retained inpatient consulting responsibilities, which required them to make arrangements ahead of time to delay clinical duties. They also needed to devise a way to handle potential interruptions during the encounters, such as putting a sign on their office door to deter would-be visitors or diverting phone calls ahead of time, as voiced by one NP:

The technology worked fine in the workflow of my day. …It was a little difficult to get here on time now once we’ve started. This time we did not have any interruptions, the phone didn’t ring, no one knocked on the door, so it went… very smoothly.

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Participant Perceptions of Ease of Use

Perceived ease of use from both the perspectives of the mock patients and clinicians was evaluated by observations, field notes, and interviews, as well as measured by the PEU questionnaire. Overall, observations and interviews of mock patient participants’ interactions with the iPad indicated that, for the most part, it was easy to use. The mock patient participants were very engaged with technology, curious about its use, and eager to participate in these sessions. They quickly became comfortable in moving the iPad to remain visible to the NP on the computer screen, comfortable seeing themselves on the screen during conversations, and comfortable in logging off at the end of their sessions, although there were some issues with the logging in procedure and starting the virtual visit, even with specific written instructions. Comfort increased with repeat encounters, as they became more familiar with the software. Most participants were eventually independent in preparing for the session. The mock patients were capable of using the iPad with minimal prompting from study staff.

The two NPs were supportive of the technology’s ease of use; however, the Web-based video conference service was somewhat burdensome for the NP initiating the virtual visit. For example, during the transition period from training to study going live, the study team and participant’s temporary user names, passwords, and virtual conference room assignments changed with minimal time to adjust. On more than one occasion, unexpected technological visual idiosyncrasies occurred (eg, the participant’s image disappeared from the screen while audio was still intact). The user needed to learn when it was necessary to toggle the alt + tab keys to recapture the picture or completely shut down the video software portal in between each participant session.

Results from the PEU questionnaire are reported in Table 3. Although seven of the eight mock patients reported that the iPad was easy to use, flexible, and not difficult to interact with, only five indicated that it was easy to get the iPad to “do what I want it to do.” The majority found it easy to remember how to perform tasks on the iPad and perceived their interactions with it to be clear and understandable. Mock patient responses not in the representative categories were neutral. No mock patient or NP responses were negative.

Table 3
Table 3
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This study provides valuable information regarding the usefulness of existing, secure technology in communicating with potential patients in hard-to-reach areas. This proof-of-concept study was the first step in addressing the resources needed and the quality of the audio and visual components to provide transitional PC enhanced with the use of virtual visits to patients living in distant rural settings. The community-dwelling adults found the iPad easy to use and that it was easy to participate in the virtual visits. The NPs also were supportive of the interactions by the virtual visits but struggled somewhat with the Web-based technology. Results of this study are similar to previous work in that the use of virtual visits in other community-based settings has been well received.21,26

In this proof-of-concept study, healthy older community-dwelling adults were study participants. All participants had at least some experience with using computers, although not all of them were experienced with video sessions. It is likely that PC patients and/or caregivers may have similar computer experience. Providing technology-enhanced care has been well received in other samples of older adults with cancer or chronic conditions or receiving hospice care.12,14,24,38–41 Use of virtual visits enhances continuity of care for PC patients transitioning from urban academic medical centers to homes in distant rural settings because of the potential to assist them with their complex care needs, minimize difficult travel, and provide support to patients who are often isolated.

Connectivity to support virtual visits in rural areas was challenging. Participants’ home computer Internet connections were configured in various ways and were often locked by local Internet providers. Cell phone data coverage, however, was widespread in rural areas and provided suitable connections for virtual visits based on the limited communication technology options in the areas where the rural participants lived and without disturbing the variety of technological services and paraphernalia configurations we found in participant homes.

The Web-based video conferencing application, while providing a dependable, encrypted video conferencing medium with integrated scheduling functions, required IT support for clinicians and study staff. The video service was chosen because of features conducive to conducting the study, such as scheduling and recording capabilities. There may be other secure, existing technology solutions that are easier to use. Use of a simpler video service such as Skype would decrease the technology burden on the clinicians and lessen the IT support requirements. The use of a scheduling system may be helpful when providing virtual visits to large numbers of patients.

Occasional poor sound quality and asynchronous audio/visual occurred; however, participants did not want to abandon the virtual visits based on intermittent poor quality. Similar to the findings of this study, inclement weather is often reported as problematic to visual and audio quality of the virtual visits. However, once the relationship between NP and patient is established, an occasional poor quality video session was well tolerated. Although visual cues are important, a secondary option could include a phone call when needed. Dansky and Bowles12 found that video, even when somewhat distorted, still provides the visual cues that are important for meaningful and effective communication. Bowles and colleagues42 identified that virtual visits provided an added dimension to the nurse-patient relationship not available through phone calls. The cost of assessing patients using video phones has also been shown to be less expensive compared with home visits.14,21,40

The results should be interpreted with an understanding of the limitations to the study. For this proof-of-concept study, we used the original TAM as our conceptual framework. Although two updated iterations of the TAM have been developed since the model’s original form, and although the model has also been extended to the unified theory of acceptance and use of technology model (UTAUT),43 the new constructs contained in these updated models were not utilized in this study. The next study with PC patients as subjects will benefit by the use of the UTAUT as the conceptual framework for exploring additional constructs. For the present study, however, the TAM was utilized simply as a means to facilitate inquiry into the efficiency and effectiveness of the technology. Subsequent iterations of the TAM would have yielded no substantive improvements in our understanding of the efficiency and effectiveness of the technology for the specialized population.

The sample was also nonrandom, derived from healthy participants living in a single state in the upper Midwest. Study participants were relatively well educated, and all had computers in their homes. Results may differ in different locations, with random selection of participants, and with actual PC patients potentially experiencing physical and psychosocial symptoms. The use of healthy patients in this proof-of-concept study was considered ethically responsible, since we anticipated an imbalance of burdens and benefits in the initial concept testing. The small sample size also limited the number of potential experiences that may be encountered in providing virtual visits to older adults living in rural settings. Nevertheless, the results provide the necessary information regarding resources needed and the quality of the audio and visual components to conduct the subsequent study of technology-enhanced transitional care with PC patients.

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Patients receiving PC have complex continuing care requirements that place demands on patients and their families.2 Patients’ continuing care needs are often unmet once patients leave the hospital with limited connections with formal support such as outpatient care, home health, and hospice. Rural patients are especially challenged because of geographical distance with resultant isolation and loneliness and limited community resources. There is a need to connect PC patients with ongoing support for their continuing care as they transition across care settings. Technology-enhanced transitional care is one such support mechanism. The results of this study provide a solid foundation for the subsequent study of the use of technology-enhanced healthcare interactions between clinicians and patients with life-limiting conditions.

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The authors thank the staff at the HAIL laboratory for use of the HAIL facility.

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Palliative care; Rural population; Technology

© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.



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