Designing for Dissemination: Engaging Stakeholders to Improve Clinical Translation of Sensor Technology
Sensor Technologies Applied to Rehabilitation in Stroke (STARS)
The Shirley Ryan AbilityLab
Submitted by Miriam Rafferty and Courtney Celian, and developed in collaboration with Michelle Zorrilla of IMPACT and Kathleen Murphy of the Center on KTDRR
This project seeks to accelerate the clinical uptake and dissemination of sensor technology by engaging stakeholders during the technology development cycle. Engineers participate in discussion panels that include clinicians who use the technology and persons who have lived experiences of stroke. Engineers also gain a deep understanding of clinical practices by reviewing summaries of data generated from electronic medical records and summaries of clinical patterns and workflows. This information will help engineers develop products that are more useful.
In September 2019, the Sensor Technologies Applied to Rehabilitation Stroke (STARS) Rehabilitation and Engineering Research Center (RERC) received a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR). Funding from the grant will help four design teams, made up of engineers and researchers, to develop sensor technologies that clinicians can use to measure impairments precisely in patients. However, several barriers make the clinical uptake of new rehab technologies difficult:
- Poor relevance to functional tasks,
- Complex devices,
- Lengthy setup time,
- Limited knowledge,
- High cost, and
- Difficulty adapting technologies between patients with different diagnoses (Celian et al., 2021).
To address these barriers, the RERC includes a Clinical Translation and Measurement Core (CTMC). The CTMC helps the STARS design teams engage with stakeholders early in the design process. This user-centered approach can improve the uptake and use of sensor devices. The CTMC also provides the design teams with background research about clinical settings. The design teams will use this information during technology development to ensure that the devices have greater potential to be adopted readily by clinicians, despite common real-world clinical constraints. The CTMC’s work through the technology development process will facilitate an implementation trial of the new technologies.
Stakeholder collaboration is a knowledge translation strategy that can improve the development, implementation, and dissemination of new technologies in clinical settings (Brownson et al., 2013; Eriksson et al., 2017; Fillion et al., 2014; Pak et al., 2015). Diverse input from many types of stakeholders (e.g., clinicians, patients, researchers) can improve the development of clinically relevant products (Davis et al., 2003). Feedback from end users can help engineers anticipate possible issues and prepare potential solutions (Vanderheiden, 2013).
The CTMC seeks to facilitate stakeholder collaborations that inform and support engineers and researchers during the development of sensor technologies. The CTMC engages stakeholders in three methods: (1) holding discussions with panels of multidisciplinary stakeholders, (2) summarizing data and clinical trends from electronic medical records, and (3) describing technology integration in clinical practices collected through observational data in real-world clinical environments, and through vignettes written by occupational therapists (OTs) and physical therapists (PTs). Due to the intensive and rigorous nature of the knowledge translation activities used, each method is conducted at different time periods with the results being ongoing.
The CTMC will facilitate three discussion panels among the diverse stakeholders and the design teams during the technology development process. Discussion panels will include two or three allied health clinicians and clinical educators from SRALab, one or two physicians, two stroke survivors, and the design team engineers and researchers. A moderator will use a semi structured interview guide to obtain balanced feedback from all panel members. The guide will help facilitate constructive feedback, focused on finding potential solutions to barriers. The timing of the discussion panels aligns with NIDILRR’s stages of development:
- Proof of concept (fall 2020): Discussions identified characteristics of measurements in the clinical area of the proposed sensory technology and offered feedback on prototypes.
- Proof of product (fall 2021): Discussions will focus on (a) measurement characteristics and the validity of the sensors in development and (b) barriers to implementation. Barriers will be a focal point throughout the design process.
- Proof of adoption stage (fall 2022): Discussions will identify facilitators for implementation, such as education and training needs. The CTMC will develop implementation blueprints to facilitate moving the sensors into pilot projects.
To help the design teams understand the use of measurement tools and the documentation constraints in clinical settings, we will summarize, from electronic medical records, data on outcome measures and technology use. The summaries will capture data about patient diagnoses, length of stay, and time spent in therapies; outcome measures completed by clinicians, and sensor technologies used in measurements and treatments. We extracted data for a 3-month time period (September–November 2019). We will repeat this audit several times during the 5-year grant period. Overall, the data will reveal trends and/or changes over time in the use of traditional outcome measures and novel sensor and rehab technologies.
To help the design teams understand how clinicians integrate technology into their day-to-day practices, the CTMC gathered information from: (1) field observations of real-time clinical environments, and (2) clinician vignettes written about decision-making during clinical treatment (Celian et al., 2021). Both forms of data will inform the design process by providing the design teams with context about clinical settings. During the field observations, trained research personnel from the CTMC collected data during approximately 30 hours of field observations. Data focused on typical therapy treatment in different settings (inpatient, outpatient, and day rehab). The data, collected in Excel, includes notes describing the devices used during clinical treatment, the measurement or therapeutic task for which the device was intended, the time it took for the therapist to complete the activity (including setup), therapist feedback and cueing provided during clinical treatment, and other general observations. Once enough clinical observations are completed to reach saturation, findings will be shared in easily digestible summaries with the design teams. For an even deeper understanding into clinical decision-making regarding technology use, the CTMC had clinicians write vignettes about treatment sessions. Uptake barriers and facilitators mentioned in the vignettes were coded using the Consolidated Framework for Implementation Research (Damschroder et al., 2009).
Formative evaluation of our knowledge translation activities are ongoing. Here are lessons learned from the formative feedback thus far:
- Discussion panels:
- Members of the design teams benefitted from coaching about simplifying their descriptions of devices (e.g., using lay language), accepting feedback openly, and allowing more time for questions and comments from others in the group.
- Patient stakeholders benefitted from preparatory coaching prior to the discussion panel to insure better understanding of the project presented during the panel. They also needed more time to reflect and discuss with a research coordinator after the panel to ensure all their feedback was incorporated into the final report.
- Clinicians benefited from having time after the meeting to reflect on the discussion panels and to provide additional feedback when the CTMC edited the report for the design teams.
- Data from electronic medical records: Data pulls will be performed approximately annually to determine the most efficient processes and most impactful data to extract from the medical record. The initial data pull provided an overview of all inpatient rehabilitation measurements to learn about different measurement cultures in different professions (physical therapy, occupational therapy, and speech language pathology). Future data pulls will extract more limited measurements across multiple clinical settings (inpatient, day rehabilitation, outpatient) to learn about different measurement cultures.
- Field observations and clinical vignettes: Observations revealed that technology use varies in different clinical environments. The written vignettes revealed that technology must have a clear relative advantage over similar activities performed without the technology to be considered appropriate and acceptable to clinicians.
- Surveys and qualitative formative evaluation: Mixed method formative evaluation will continue.
We will also create a summative evaluation at the end of the 5-year grant. The summative evaluation will note the impact that each of our three activities had on the development, implementation, and dissemination of sensors in the final pilot of the implementation project.
NIDILRR Project Name: Sensor Technologies Applied to Rehabilitation in Stroke (STARS)
Parent Organization: The Shirley Ryan AbilityLab
Physical Address: 355 E. Erie St., Chicago, IL 60657
Key Contact: Miriam Rafferty, PT, DPT, PhD, firstname.lastname@example.org, 312-238-7233
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