Brief communication: patient satisfaction with the use of tablet computers: a pilot study in two outpatient home dialysis clinics

Despite the knowledge that patients living with end stage renal disease have compromised health related quality of life, measurement of this phenomenon in clinical practice is rare.

Health related quality of life measurement in clinical settings may be conducted expediently with the use of tablet computers. Participants’ overall satisfaction with the use of the tablet computers for completing the measures was generally high. Satisfaction was not related to age gender, time involved, experience, comfort, or health status.

End stage renal disease (ESRD) significantly influences patients’ perceptions of their health and the quality of their lives. Health-related quality of life (HRQOL) is subjective and it can only be accurately assessed by the patient [1]. Although there is ample research identifying that HRQOL is compromised for patients living with ESRD [2],[3], measurement of HRQOL in clinical practice is relatively uncommon [4]. Use of computer-based technologies may facilitate use of these measures in practice, if they are acceptable to patients. Hence, the aim of this study was to assess patient satisfaction with use of the tablet computer for completion of HRQOL and symptom assessment measures in outpatient home hemodialysis and peritoneal dialysis clinics and to ascertain the time required to complete these measures. The research questions were: How satisfied are outpatient home hemodialysis and peritoneal dialysis patients with use of tablet computers to score HRQOL and symptom assessment measures? How long did it take for participants to complete the measures using tablet computers?

Recently, in the United States, the Centers for Medicare and Medicaid Services (CMS) [5] mandated that every dialysis unit must routinely measure HRQOL of patients at least annually as a prerequisite for coverage. The rationale for this CMS requirement was based in part on the finding that lower HRQOL scores are good predictors of mortality and hospitalization [6],[7].

There is some recognition that HRQOL data could be useful to practitioners. Researchers have found that use of these data had a positive impact on communication between physicians and patients (without prolonging interactions) [8], helped physicians to identify symptoms that otherwise might have been unnoticed [9], and impacted healthcare professionals when patient reported outcome (PROs) were used as a management tool in an outpatient setting with a specific patient population [10]. However, use of HRQOL and other PROs has been limited because paper and pencil administration precludes rapid scoring and presentation of results. Routine HRQOL assessment, with the use of touch-screen computers, has been found to significantly improve nurses’ awareness of patients’ experiences of pain, level of functioning, and overall quality of life [11], and increase communication and management of patients, without prolonging the length of patient visits [12].

Researchers cannot necessarily assume that translations of PROs from paper to electronic versions are equivalent [13]–[15]. The need to test measurement equivalence is determined by the level of modification required. Usability testing encompasses formal documentation of respondents’ ability to use the chosen electronic platform, follow instructions, and answer the questions [13].

Participant satisfaction was high with 66% reporting that they were “very satisfied”, 7% “satisfied”, 2% “slightly satisfied”, and 18% “neutral”; 3.6% reported dissatisfaction. The mean satisfaction score was 5.11 (SD = 1.6) on the 7-point scale. Again, using a 7-point scale, the mean computer experience score was 2.56 (SD = 1.7), and comfort using computer technology was 2.48 (SD = 1.4). A total of 75% of participants reported they had between no computer experience and average experience, yet 78% said they had fair to excellent comfort with computer technology.

Bivariate correlations were examined between satisfaction and age, gender, time, experience, comfort, and the global health item from the KDQOL-36. Satisfaction with use of the tablet computers was not correlated with either experience or comfort. We hypothesized that more computer experience would be correlated with greater comfort with technology; a one-tailed Spearman’s correlation coefficient between comfort and experience was 0.7, which was statistically significant (p < 0.01).

Participants’ overall satisfaction with use of the tablet computer for completing the instruments was generally high and it seems that satisfaction is not related to age, gender, time involved, experience, comfort, and health status. Perhaps other contextual factors, such as design of the app, and interviewer instructions and support may have influenced their satisfaction. Because only 4% of the sample had ever used a tablet computer previously, initial instruction was required to use the device and respond to questions. It is likely that less instruction will be required for administration of the questionnaires using this platform at future visits. We anticipate that in the future, as electronic devices become more common and as baby-boomers enter retirement, less education/support for the use of tablet computers will be required for patients to use them in clinical settings.

Confirming our findings, Chang et al. [15] also concluded that age and previous computer experience did not explain acceptance of an electronic platform. Pouwer et al. [22] also found that e-PROs were very easy for research participants to use even if they had little computer experience.

Outpatient clinic settings are considered to be ideal for use of PRO feedback as a management tool with particular populations, such as ESRD; the course of action with targeted solutions may be clearer to practitioners, and there may be greater room for improvement of outcomes and reports of HRQOL with patients who present with advanced symptoms [10],[23].

Despite having a 68% response rate, the study was limited due to its small sample size. Data were collected from self-selected patients using a home dialysis modality and they were not representative of the larger ESRD population. Further, patients who were experiencing medical crises were not included, so healthier ESRD patients were overrepresented. The study was also limited in that it only included participants from one geographic area on the west coast of Canada. Another limitation is the lack of psychometric testing for the measure of satisfaction, which was developed for the purposes of the study and modeled on similar measures. Another concern was that in our study, 3.6% of participants reported that they were “very dissatisfied” with using the tablet. However, in the interviews that followed survey completion, these same participants said that they enjoyed using the technology, suggesting that they may have made errors in the rating. This error rate may be an area for future research pertaining to the use e-PROs.

We found that patient satisfaction was high with completion of HRQOL and symptom assessment measures on tablet computers. The time required to complete the surveys was modest. As electronic capture of patient report data becomes routine in healthcare settings, use of HRQOL assessment for clinical purposes may be facilitated through use of tablet computers. This is important both for practice and research settings where PRO results have the potential to be analyzed in real-time to facilitate patient management and to enhance communication between patients and healthcare providers [8]–[12],[15]. The ease of electronic capture of PROs may offer opportunities to use HRQOL data for patient care and/or quality improvement programs.

^aThe KDQOL Complete database is housed on a server in the United States, which means that under the US Patriot Act, there is a possibility that information about the participant could be accessed without their knowledge or consent by the US government. To preserve confidentiality of data, participants were only identified by their assigned ID codes on the KDQOL Complete website. Participants were also informed of this on the consent form.

KSM, PhD, RN is a Postdoctoral Fellow through KRESCENT (Kidney Research Scientist Core Education and National Training Program), 2011-2014, in the Faculty of Nursing at the University of Alberta. AM, PhD, RN, FCAHS is Dean and Professor of the Faculty of Nursing at the University of Alberta.