A positive digital patient experience can improve health and care outcomes, but a positive digital patient experience does not just happen; it refers to understanding, evaluating, and improving the entire patient journey through digital health. Human-centered design is often applied to understand patients’ needs and improve patient experiences when designing digital health solutions. However, human-centered design for digital health is demanding. It often involves multiple stakeholders with different values and requires evidence for implementation. Patient perspectives routinely differ from those of other stakeholders. Even within the same patient group, individual situations are also often different from each other. Yet, it is not always apparent that patients were engaged in the design process and were empowered enough to voice their opinions. Listen to the patients’ voices and uncover their unique needs; designers are expected to speak for patients. This thesis aims to support designers in improving the quality of care in digital health by defining, evaluating, and designing digital patient experiences. This thesis is divided into three parts to achieve this goal.

Part A: defining digital patient experiences
To build a common understanding of digital patient experiences among design, technology, and healthcare communities and to facilitate transdisciplinary knowledge exchange and learning between these different fields for driving digital health innovation, this part contains one chapter and focuses on defining digital patient experiences. In chapter 2, we proposed the term “digital patient experience” as a common phrase to describe the patient experience in digital health and defined “digital patient experience” by synthesizing the reported patient experience or user experience of varied digital health interventions from multiple reviews. Specifically, the concept of the digital patient experience was defined as “the sum of all interactions affected by a patient’s behavioral determinants, framed by digital technologies, and shaped by organizational culture, that influence patient perceptions across the continuum of care channelling digital health.” In addition, we identified information on influencing factors and summarized them into 9 categories (i.e., patient capability, patient opportunity, patient motivation, intervention technology, intervention functionality, intervention interaction design, organizational environment, physical environment, and social environment). These categories were classified into positive, negative, and double-edged factors based on their positive, negative, or dynamic impacts on digital patient experiences. Furthermore, we uncovered 4 design constructs (i.e., personalized, information, navigation, and visual design) and 3 common design methods (i.e., user-centered design or human-centered design, co-design, and inclusive design) as design considerations for addressing digital patient experiences. Finally, we proposed a framework and 9 design guidelines to help digital health designers and developers improve digital patient experiences throughout the entire design process.

Part B: evaluating digital patient experiences
In the second part, we discussed the importance of evaluating digital patient experiences, developed an evaluation guide to help digital health researchers, designers, and developers further evaluate digital patient experiences, and conducted a case study to evaluate digital patient experiences in a clinical setting. Following the research findings of Chapter 2 on defining the digital patient experience, in Chapter 3, we first identified five typical evaluation objectives and related stakeholder groups. We then described potential evaluation timing considerations in terms of 4 intervention maturity stages and 3 evaluation timings. We also collected knowledge on evaluation indicators of digital patient experiences and grouped them into 3 categories: intervention outputs, patient outcomes, and health care system impact. These were then classified into 9 themes (i.e., intervention functionality, usability, care quality, patient emotional outcomes, perceptual outcomes, capability outcomes, behavioral outcomes, clinical outcomes, and system economic outcomes) and 22 subthemes. Furthermore, we noted a set of common study designs, data collection methods, and instruments, as well as data analysis methods, that can be used or adapted to evaluate digital patient experiences. To facilitate the standard evaluation of digital patient experiences, we recommend 6 directions for further research on digital patient experience evaluation. In Chapter 4, we conducted a prospective observational study to evaluate digital patient experiences of using virtual reality distraction in wound care for pain management. This chapter can be used as an example for guiding digital health designers and developers to evaluate digital patient experiences in clinical settings. It also offers inspiration to improve the design, development, and implementation of the virtual reality distraction in wound care for better digital patient experiences. For example, We found that patients who had high levels of technology acceptance, pain during previous wound care, or previously used VR distraction in wound care were more willing to use VR distraction in wound care. These findings indicate patient behavioral determinants have an influence on their intention to use digital health solutions, which supports our findings in Chapter 2 that patients’ behavioral determinants influence patient perceptions of using digital health. In addition, in Chapter 4, no evidence was found on the effectiveness of virtual reality distraction in significantly reducing pain or anxiety during wound care. Although many studies have indicated the effectiveness of using virtual reality distraction in wound care for pain management, our research results do not support this argument. To avoid ineffective digital health implementation, we encourage more rigorous research on investigating the effectiveness of virtual reality distraction in wound care or how to improve its effectiveness through design. Besides, on average, the digital patient experience and patient satisfaction with using virtual reality distraction in wound care were positive, which reveals that although digital health solutions do not always lead to a significant better health outcome, they can contribute to a better treatment experience, which is also very valuable.

Part C: designing digital patient experiences
In the final part, we focus on guiding the design of digital patient experiences. We investigated the general human-centered design process in digital health and synthesized all research findings to generate a web-based design guide to support the understanding, evaluation, and improvement of digital patient experiences. In chapter 5, we mapped the (re)design and continuous improvement processes in digital health into 8 stages and grouped them into 4 phases: preparation, problem-thinking, problem-solving, and implementation. We also identified 12 challenges and classified them into 4 categories: contextual, practical, managerial, and commercial challenges. Furthermore, we outlined 8 corresponding strategies, recommended by the participating designers, to address each challenge type. Finally, we created a framework including design deliverables, activities, involved stakeholders, design challenges, and related design strategies for each design stage. The framework not only aids designers in understanding the design practices in the healthcare industry but also guides them when managing their digital health design processes towards the improvements of digital patient experiences. In chapter 6, we presented a web-based digital patient experience design guide that synthesized the previous research findings, and we further evaluated the design guide. We show that our digital patient experience design guide was evaluated as usable with good content quality, but that it needs further improvement in providing relevant, detailed, and resourceful content, intuitive and interactive interfaces, as well as simple and ready-to-use templates. We believe these improvement insights are relevant for developing and evaluating design guides in general. In addition, participants reported conflicting tensions in the guide’s design, requiring a balance between specific and general, less and more, as well as fixed and flexible. These tensions reveal the diversity and conflicts in students’ needs for useful and effective design guides. On the one hand, users want design guides to hold relevant, detailed information and content, provide a systematic overview, include complete conceptual explanations, detailed design cases, and integrated design resources, enabling them to use the design guide as a resource library for flexible exploration. On the other hand, they want a design guide to be simple and easy to use, offering concise and clear information with low learning and usage costs, enabling them to effortlessly complete efficient designs. We believe this study serves as an example, inspiring future design researchers to develop and evaluate their own design guides.

In conclusion, this thesis contributes theoretically (via new knowledge) and practically (via the design guide) to facilitate a scientific impact on the definition, evaluation, and design of digital patient experiences from a human-centered design perspective, thus, supporting the improvement of the quality of care in digital health solutions.@en

BACKGROUND: The increasing prevalence of DH applications has outpaced research and practice in digital health (DH) evaluations. Patient experience (PEx) was reported as one of the challenges facing the health system by the World Health Organization. To generate evidence on DH and promote the appropriate integration and use of technologies, a standard evaluation of PEx in DH is required. OBJECTIVE: This study aims to systematically identify evaluation timing considerations (ie, when to measure), evaluation indicators (ie, what to measure), and evaluation approaches (ie, how to measure) with regard to digital PEx. The overall aim of this study is to generate an evaluation guide for further improving digital PEx evaluation. METHODS: This is a 2-phase study parallel to our previous study. In phase 1, literature reviews related to PEx in DH were systematically searched from Scopus, PubMed, and Web of Science databases. Two independent raters conducted 2 rounds of paper screening, including title and abstract screening and full-text screening, and assessed the interrater reliability for 20% (round 1: 23/115 and round 2: 12/58) random samples using the Fleiss-Cohen coefficient (round 1: k1=0.88 and round 2: k2=0.80). When reaching interrater reliability (k>0.60), TW conducted the rest of the screening process, leaving any uncertainties for group discussions. Overall, 38% (45/119) of the articles were considered eligible for further thematic analysis. In phase 2, to check if there were any meaningful novel insights that would change our conclusions, we performed an updated literature search in which we collected 294 newly published reviews, of which 102 (34.7%) were identified as eligible articles. We considered them to have no important changes to our original results on the research objectives. Therefore, they were not integrated into the synthesis of this review and were used as supplementary materials. RESULTS: Our review highlights 5 typical evaluation objectives that serve 5 stakeholder groups separately. We identified a set of key evaluation timing considerations and classified them into 3 categories: intervention maturity stages, timing of the evaluation, and timing of data collection. Information on evaluation indicators of digital PEx was identified and summarized into 3 categories (intervention outputs, patient outcomes, and health care system impact), 9 themes, and 22 subthemes. A set of evaluation theories, common study designs, data collection methods and instruments, and data analysis approaches was captured, which can be used or adapted to evaluate digital PEx. CONCLUSIONS: Our findings enabled us to generate an evaluation guide to help DH intervention researchers, designers, developers, and program evaluators evaluate digital PEx. Finally, we propose 6 directions for encouraging further digital PEx evaluation research and practice to address the challenge of poor PEx.

@en

Design is expanding its influence on shaping future healthcare. Ideally, designers apply human-centered design and human factors that introduce theory, principles, and methods to design to optimize people’s healthcare experiences in both digital and non-digital environments. To discuss and implement experience design in healthcare, consensus about experience design in healthcare is needed. Objectives: Therefore, the purpose of this study is to investigate designers’ views on experience design in health, and to uncover their understanding about three experience design concepts, i.e., user experience (UX), patient experience (PEx), and digital patient experience (dPEx). We conducted online semi-structured interviews study with convenience samples who met the eligibility. We used ATLAS.ti for an in-depth data coding following thematic analysis. 24 international designers of digital health solutions, either in industry or in academia took part in the interviews. We found the similarities and differences mentioned between healthcare design and non-healthcare design relate to (1) design principles, (2) user attributes, and (3) design contexts. Furthermore, the differences between UX, PEx, and dPEx can be mapped on five dimensions: people, contexts, purposes, means, and usage scenarios. These insights can help designers and human factors specialists build a common design language for experience design in healthcare. Our study can also assist designers and human factors specialists with experience design in digital health by pointing out the areas where design thinking generally is appropriate and the places where particular expertise in healthcare design is needed.

@en

Background Digital health (DH) brings considerable benefits, but it comes with potential risks. Human Factors (HF) play a critical role in providing high-quality and acceptable DH solutions. Consultation with designers is crucial for reflecting on and improving current DH design practices. Objectives We investigated the general DH design processes, challenges, and corresponding strategies that can improve the digital patient experience (PEx). Methods A semi-structured interview study with 24 design professionals. All audio recordings were transcribed, deidentified, grammatically corrected, and imported into ATLAS.ti for data analysis. Three coders participated in data coding following the thematic analysis approach. Results We identified eight DH design stages and grouped them into four phases: preparation, problem-thinking, problem-solving, and implementation. The analysis presented twelve design challenges associated with contextual, practical, managerial, and commercial aspects that can hinder the design process. We identified eight common strategies used by respondents to tackle these challenges. Conclusions We propose a Digital Health Design (DHD) framework to improve the digital PEx. It provides an overview of design deliverables, activities, stakeholders, challenges, and corresponding strategies for each design stage.@en

Since Covid-19, digital health interventions (DHIs) have been embraced as never before. The pandemic led to many new challenges, including the patient experience in digital health care delivery. In this literature study, we identified and synthesized factors that impact patient experience in digital health (dPEx), and reviewed the methods and strategies relevant to its design and implementation. We conducted an umbrella review including 15 reviews representing 543 studies. Four themes were identified that describe design-relevant factors that impact dPEx: individual context, content, technical issues, and design features. We propose a preliminary framework to explain the relationship between each factor and support user-centered design efforts. Further research is needed to identify which factors have the most impact.

@en

Background: The adoption and use of technology have significantly changed health care delivery. Patient experience has become a significant factor in the entire spectrum of patient-centered health care delivery. Digital health facilitates further improvement and empowerment of patient experiences. Therefore, the design of digital health is served by insights into the barriers to and facilitators of digital patient experience (PEx). Objective: This study aimed to systematically review the influencing factors and design considerations of PEx in digital health from the literature and generate design guidelines for further improvement of PEx in digital health. Methods: We performed an umbrella systematic review following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology. We searched Scopus, PubMed, and Web of Science databases. Two rounds of small random sampling (20%) were independently reviewed by 2 reviewers who evaluated the eligibility of the articles against the selection criteria. Two-round interrater reliability was assessed using the Fleiss-Cohen coefficient (k1=0.88 and k2=0.80). Thematic analysis was applied to analyze the extracted data based on a small set of a priori categories. Results: The search yielded 173 records, of which 45 (26%) were selected for data analysis. Findings and conclusions showed a great diversity; most studies presented a set of themes (19/45, 42%) or descriptive information only (16/45, 36%). The digital PEx-related influencing factors were classified into 9 categories: patient capability, patient opportunity, patient motivation, intervention technology, intervention functionality, intervention interaction design, organizational environment, physical environment, and social environment. These can have three types of impacts: positive, negative, or double edged. We captured 4 design constructs (personalization, information, navigation, and visualization) and 3 design methods (human-centered or user-centered design, co-design or participatory design, and inclusive design) as design considerations. Conclusions: We propose the following definition for digital PEx: "Digital patient experience is the sum of all interactions affected by a patient's behavioral determinants, framed by digital technologies, and shaped by organizational culture, that influence patient perceptions across the continuum of care channeling digital health." In this study, we constructed a design and evaluation framework that contains 4 phases-define design, define evaluation, design ideation, and design evaluation-and 9 design guidelines to help digital health designers and developers address digital PEx throughout the entire design process. Finally, our review suggests 6 directions for future digital PEx-related research.

@en

To support developing new playful product for older adults, this paper briefly reviewed a range of existing playful products, and describes how they could be strategically deconstructed and refactored from the perspective of the five interaction elements (person, purpose, means, contexts, and actions). A design framework combining case analogies and persona methods was proposed. The formalized design strategy of persona and case-based interaction elements analysis system that mainly considers two parts in the design process which are called ‘inspiration cases’ and ‘typical users’ in this paper. The strategy can be applied to the process of re-designing a specific class of playful products, such as tangible toys or digital games, for particular older adults.

@en