Participatory Development of an Integrated, eHealth-Supported, Educational Care Pathway (Diabetes Box) for People With Type 2 Diabetes: Development and Usability Study

Abstract

Background: Type 2 diabetes (T2D) tremendously affects patient health and health care globally. Changing lifestyle behaviors can help curb the burden of T2D. However, health behavior change is a complex interplay of medical, behavioral, and psychological factors. Personalized lifestyle advice and promotion of self-management can help patients change their health behavior and improve glucose regulation. Digital tools are effective in areas of self-management and have great potential to support patient self-management due to low costs, 24/7 availability, and the option of dynamic automated feedback. To develop successful eHealth solutions, it is important to include stakeholders throughout the development and use a structured approach to guide the development team in planning, coordinating, and executing the development process.

Objective: The aim of this study is to develop an integrated, eHealth-supported, educational care pathway for patients with T2D.

Methods: The educational care pathway was developed using the first 3 phases of the Center for eHealth and Wellbeing Research roadmap: the contextual inquiry, the value specification, and the design phase. Following this roadmap, we used a scoping review about diabetes self-management education and eHealth, past experiences of eHealth practices in our hospital, focus groups with health care professionals (HCPs), and a patient panel to develop a prototype of an educational care pathway. This care pathway is called the Diabetes Box (Leiden University Medical Center) and consists of personalized education, digital educational material, self-measurements of glucose, blood pressure, activity, and sleep, and a smartphone app to bring it all together.

Results: The scoping review highlights the importance of self-management education and the potential of telemonitoring and mobile apps for blood glucose regulation in patients with T2D. Focus groups with HCPs revealed the importance of including all relevant lifestyle factors, using a tailored approach, and using digital consultations. The contextual inquiry led to a set of values that stakeholders found important to include in the educational care pathway. All values were specified in biweekly meetings with key stakeholders, and a prototype was designed. This prototype was evaluated in a patient panel that revealed an overall positive impression of the care pathway but stressed that the number of apps should be restricted to one, that there should be no delay in glucose value visualization, and that insulin use should be incorporated into the app. Both patients and HCPs stressed the importance of direct automated feedback in the Diabetes Box.

Conclusions: After developing the Diabetes Box prototype using the Center for eHealth and Wellbeing Research roadmap, all stakeholders believe that the concept of the Diabetes Box is useful and feasible and that direct automated feedback and education on stress and sleep are essential. A pilot study is planned to assess feasibility, acceptability, and usefulness in more detail.

Keywords: CeHRes; CeHRes roadmap; Center for eHealth and Wellbeing Research; activation; behavioral; cardiovascular disease; development; diabetes; diabetes mellitus; diet; dietitian; digital consultation; education; endocrine; endocrinology; exercise; feasibility; focus group; glucose; glucose regulation; heath care professional; insulin; lifestyle factor; medical; mobile phone; nurse; patient education; patient education as topic; psychological; psychologist; self-management; sleep; stress; tele; telemedicine; type 2; type 2 diabetes; usability.

Figure 1

Overview of the CeHRes roadmap showing the different phases and formative evaluation (adapted from van Gemert-Pijnen et al [31]). CeHReS: Center for eHealth and Wellbeing Research.

Figure 2

Overview of aspects in every phase. Note that this paper focuses on the contextual inquiry, the value specification, and the design phase [31].

Figure 3

Screenshots of the LUMCCare app from left to right: (A) the home screen showing general well-being, weight, blood pressure, activity, and questionnaires, (B) the weight screen, and (C) the activity screen.

Figure 4

Overview of the educational pathway for patients with T2D using the Diabetes Box.

Figure 5

Screenshots of the new modalities of the LUMCCare app from left to right: (A) the screen to register a new intake, either food or drink, with a photo; (B) the sleep screen showing an average score based on estimated duration, interruptions, and regularity; and (C) the glucose screen combined with the diet screen showing the photos of intakes in the glucose graph.