The eClinical Care Pathway Framework: a novel structure for creation of online complex clinical care pathways and its application in the management of sexually transmitted infections

BackgroundDespite considerable international eHealth impetus, there is no guidance on the development of online clinical care pathways. Advances in diagnostics now enable self-testing with home diagnosis, to which comprehensive online clinical care could be linked, facilitating completely self-directed, remote care. We describe a new framework for developing complex online clinical care pathways and its application to clinical management of people with genital chlamydia infection, the commonest sexually transmitted infection (STI) in England.MethodsUsing the existing evidence-base, guidelines and examples from contemporary clinical practice, we developed the eClinical Care Pathway Framework, a nine-step iterative process. Step 1: define the aims of the online pathway; Step 2: define the functional units; Step 3: draft the clinical consultation; Step 4: expert review; Step 5: cognitive testing; Step 6: user-centred interface testing; Step 7: specification development; Step 8: software testing, usability testing and further comprehension testing; Step 9: piloting. We then applied the Framework to create a chlamydia online clinical care pathway (Online Chlamydia Pathway).ResultsUse of the Framework elucidated content and structure of the care pathway and identified the need for significant changes in sequences of care (Traditional: history, diagnosis, information versus Online: diagnosis, information, history) and prescribing safety assessment. The Framework met the needs of complex STI management and enabled development of a multi-faceted, fully-automated consultation.ConclusionThe Framework provides a comprehensive structure on which complex online care pathways such as those needed for STI management, which involve clinical services, public health surveillance functions and third party (sexual partner) management, can be developed to meet national clinical and public health standards. The Online Chlamydia Pathway’s standardised method of collecting data on demographics and sexual behaviour, with potential for interoperability with surveillance systems, could be a powerful tool for public health and clinical management.

[1]  A. Miners,et al.  Testing for sexually transmitted infections among students: a discrete choice experiment of service preferences , 2013, BMJ Open.

[2]  Anne M Johnson,et al.  Can we improve partner notification rates through expedited partner therapy in the UK? Findings from an exploratory trial of Accelerated Partner Therapy (APT) , 2022 .

[3]  K. Ghanem,et al.  Audio computer assisted self interview and face to face interview modes in assessing response bias among STD clinic patients , 2005, Sexually Transmitted Infections.

[4]  Jo Gibbs,et al.  Can remote STI/HIV testing and eClinical Care be compatible with robust public health surveillance? , 2015, Digital Health.

[5]  G. Willis,et al.  Research Synthesis: The Practice of Cognitive Interviewing , 2007 .

[6]  I. Fernando,et al.  Testing times: testing patient acceptance and ability to self-screen for a No-Talk Testing service , 2013, International journal of STD & AIDS.

[7]  Ross Shegog,et al.  The intersection of youth, technology, and new media with sexual health: moving the research agenda forward. , 2012, The Journal of adolescent health : official publication of the Society for Adolescent Medicine.

[8]  N. Low,et al.  Effectiveness and cost-effectiveness of traditional and new partner notification technologies for curable sexually transmitted infections: observational study, systematic reviews and mathematical modelling. , 2014, Health technology assessment.

[9]  K. Ghanem,et al.  The role of speculum and bimanual examinations when evaluating attendees at a sexually transmitted diseases clinic , 2006, Sexually Transmitted Infections.

[10]  Voula Gkatzidou,et al.  O22.4 What Are Young People’s Perceptions of Using Electronic Self-Tests For STIs Linked to Mobile Technology For Diagnosis and Care (eSTI2)? , 2013, Sexually Transmitted Infections.

[11]  Marie A. Smith,et al.  E-Prescribing: Clinical Implications for Patients with Diabetes , 2009, Journal of diabetes science and technology.

[12]  L. Vodstrcil,et al.  Computer-Assisted Self Interviewing in Sexual Health Clinics , 2010, Sexually transmitted diseases.

[13]  Talk or Text to Tell? How Young Adults in Canada and South Africa Prefer to Receive STI Results, Counseling, and Treatment Updates in a Wireless World , 2013, Journal of health communication.

[14]  Rajul Patel,et al.  Young persons' access to genitourinary medicine clinics in the UK: a cross-sectional survey , 2012, Sexually Transmitted Infections.

[15]  Borja Martínez-Pérez,et al.  Mobile Health Applications for the Most Prevalent Conditions by the World Health Organization: Review and Analysis , 2013, Journal of medical Internet research.

[16]  G. Kinghorn.  Patient access to GUM clinics , 2001, Sexually transmitted infections.

[17]  M. Nahata.  Drug interactions with azithromycin and the macrolides: an overview. , 1996, The Journal of antimicrobial chemotherapy.

[18]  L. Tarassenko,et al.  Clinical and cost effectiveness of mobile phone supported self monitoring of asthma: multicentre randomised controlled trial , 2012, BMJ : British Medical Journal.

[19]  M. Lim,et al.  Trends in sexual behavior, testing, and knowledge in young people; 2006-2011. , 2012, Sexually transmitted diseases.

[20]  K. Holmes,et al.  Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection. , 2005, The New England journal of medicine.

[21]  K. Radcliffe,et al.  UK national guideline for the management of infection with Chlamydia trachomatis , 2016 .

[22]  M. Bachmann,et al.  Evaluation of a systematic postal screening and treatment service for genital Chlamydia trachomatis, with remote clinic access via the internet: a cross-sectional study, East of England , 2012, Sexually Transmitted Infections.

[23]  S. Bull,et al.  Social media-delivered sexual health intervention: a cluster randomized controlled trial. , 2012, American Journal of Preventive Medicine.

[24]  Alan P Baptist,et al.  Social Media, Text Messaging, and Email—Preferences of Asthma Patients between 12 and 40 Years Old , 2011, The Journal of asthma : official journal of the Association for the Care of Asthma.

[25]  D. Price,et al.  Understanding the potential role of mobile phone‐based monitoring on asthma self‐management: qualitative study , 2007, Clinical and experimental allergy : journal of the British Society for Allergy and Clinical Immunology.

[26]  C. May.  A rational model for assessing and evaluating complex interventions in health care , 2006, BMC Health Services Research.

[27]  Jeremy C Wyatt,et al.  Evaluation of ehealth systems and services , 2004, BMJ : British Medical Journal.

[28]  Patrick J Heagerty,et al.  A Comparison Between Audio Computer-Assisted Self-Interviews and Clinician Interviews for Obtaining the Sexual History , 2004, Sexually transmitted diseases.

[29]  Holly Blake,et al.  Mobile phone technology in chronic disease management. , 2008, Nursing standard (Royal College of Nursing (Great Britain) : 1987).

[30]  K. Rabe,et al.  Cost-Effectiveness of Internet-Based Self-Management Compared with Usual Care in Asthma , 2011, PloS one.

[31]  M. O'Donnell,et al.  Assessment of the quality of care and financial impact of a virtual renal clinic compared with the traditional outpatient service model , 2011, International journal of clinical practice.

[32]  K. Wellings,et al.  The development of a multi-criteria decision analysis aid to help with contraceptive choices: My Contraception Tool , 2013, Journal of Family Planning and Reproductive Health Care.

[33]  Improving Questions on Sexual Partnerships: Lessons Learned from Cognitive Interviews for Britain’s Third National Survey of Sexual Attitudes and Lifestyles (“Natsal-3”) , 2012, Archives of sexual behavior.

[34]  J. Haar,et al.  Can text messaging results reduce time to treatment of Chlamydia trachomatis? , 2008, Sexually Transmitted Infections.

[35]  Syed Tariq Sadiq,et al.  A randomised controlled trial of computer-assisted interviewing in sexual health clinics , 2010, Sexually Transmitted Infections.

[36]  G. Hart,et al.  Qualitative analysis of psychosocial impact of diagnosis of Chlamydia trachomatis: implications for screening , 2001, BMJ : British Medical Journal.

[37]  Elizabeth Murray,et al.  What Young People Want From a Sexual Health Website: Design and Development of Sexunzipped , 2012, Journal of medical Internet research.

[38]  Paul Turner,et al.  Patients at the Centre: Methodological Considerations for Evaluating Evidence from Health Interventions Involving Patients Use of Web-Based Information Systems , 2010, The open medical informatics journal.

[39]  M. Pitts,et al.  Use of the Delphi sorting technique to establish a core sexual history , 2006, International Journal of STD and AIDS.

[40]  C. O'mahony,et al.  Use of Telephonetics® RESULTSTM computer-facilitated telephone system with automatic results upload , 2011, International journal of STD & AIDS.

[41]  David H. Martin,et al.  Application of computer-assisted interviews to sexual behavior research. , 1999, American journal of epidemiology.

[42]  Wendy Macdowall,et al.  Methodology of the third British National Survey of Sexual Attitudes and Lifestyles (Natsal-3) , 2013, Sexually Transmitted Infections.

[43]  Holly Blake,et al.  Innovation in practice: mobile phone technology in patient care. , 2008, British journal of community nursing.

[44]  C Michael Stein,et al.  Azithromycin and the risk of cardiovascular death. , 2012, The New England journal of medicine.

[45]  Catherine H Mercer,et al.  Building the bypass—implications of improved access to sexual healthcare: evidence from surveys of patients attending contrasting genitourinary medicine clinics across England in 2004/2005 and 2009 , 2011, Sexually Transmitted Infections.

[46]  R. Rosenfeld,et al.  Authority , 2010, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[47]  V. Knight,et al.  Clients' preferred methods of obtaining sexually transmissable infection or HIV results from Sydney Sexual Health Centre. , 2013, Sexual health.

[48]  S. Sizmur,et al.  Development of a validated patient satisfaction survey for sexual health clinic attendees , 2010, International journal of STD & AIDS.

[49]  E. Murray,et al.  Interactive computer-based interventions for sexual health promotion. , 2010, The Cochrane database of systematic reviews.

[50]  J. Fortenberry,et al.  Patient-Delivered Partner Treatment With Azithromycin to Prevent Repeated Chlamydia trachomatis Infection Among Women: A Randomized, Controlled Trial , 2003, Sexually transmitted diseases.

[51]  William Brown,et al.  Assessment of the Health IT Usability Evaluation Model (Health-ITUEM) for evaluating mobile health (mHealth) technology , 2013, J. Biomed. Informatics.

[52]  Voula Gkatzidou,et al.  User interface design for mobile-based sexual health interventions for young people: Design recommendations from a qualitative study on an online Chlamydia clinical care pathway , 2015, BMC Medical Informatics and Decision Making.

[53]  M. Brook,et al.  Is accelerated partner therapy a feasible and acceptable strategy for rapid partner notification in the UK?: a qualitative study of genitourinary medicine clinic attenders , 2009, International journal of STD & AIDS.

[54]  N. Low,et al.  Developing national outcome standards for the management of gonorrhoea and genital chlamydia in genitourinary medicine clinics , 2004, Sexually Transmitted Infections.

[55]  M. Lim,et al.  SMS STI: A Review of the Uses of Mobile Phone Text Messaging in Sexual Health , 2008, International journal of STD & AIDS.

[56]  C. Dowrick,et al.  Complex interventions , 2022, International Review of Sport and Exercise Psychology.

[57]  T. Nolin,et al.  Antimicrobial-associated QT interval prolongation: pointes of interest. , 2006, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[58]  Niall Boyce.  The Lancet Technology: June, 2012 , 2012, The Lancet.

[59]  Kaye Wellings,et al.  Teenage sexuality, fertility and life chances. Report prepared for the Department of Health using data from the National Survey of Sexual Attitudes and Lifestyles , 1996 .

[60]  C. Mercer,et al.  Where do young men want to access STI screening? A stratified random probability sample survey of young men in Great Britain , 2012, Sexually Transmitted Infections.

[61]  D. Cella,et al.  Developing a Valid Patient‐Reported Outcome Measure , 2011, Clinical pharmacology and therapeutics.

[62]  Emily C. Pike,et al.  Mobile Phone Applications for the Care and Prevention of HIV and Other Sexually Transmitted Diseases: A Review , 2013, Journal of medical Internet research.

[63]  Jacques Bouaud,et al.  Design of a Decision Support System for Chronic Diseases Coupling Generic Therapeutic Algorithms with Guideline-Based Specific Rules , 2006, MIE.

[64]  Elizabeth Murray,et al.  The Sexunzipped Trial: Young People’s Views of Participating in an Online Randomized Controlled Trial , 2013, Journal of medical Internet research.

[65]  Wanda Pratt,et al.  Healthcare in the pocket: Mapping the space of mobile-phone health interventions , 2012, J. Biomed. Informatics.

[66]  A. Sullivan,et al.  2012 BASHH statement on partner notification for sexually transmissible infections , 2013, International journal of STD & AIDS.

[67]  M. Pitts,et al.  A randomised controlled trial comparing computer-assisted with face-to-face sexual history taking in a clinical setting , 2006, Sexually Transmitted Infections.

[68]  C. Rietmeijer,et al.  Evaluation of a Testing-Only “Express” Visit Option to Enhance Efficiency in a Busy STI Clinic , 2008, Sexually transmitted diseases.

[69]  N. Low,et al.  Strategies for partner notification for sexually transmitted infections, including HIV. , 2013, The Cochrane database of systematic reviews.

[70]  J. Sterne,et al.  Coverage and uptake of systematic postal screening for genital Chlamydia trachomatis and prevalence of infection in the United Kingdom general population: cross sectional study , 2005, BMJ : British Medical Journal.

[71]  H. Svanström,et al.  Use of azithromycin and death from cardiovascular causes. , 2013, The New England journal of medicine.

[72]  E. Balas,et al.  Healthcare via cell phones: a systematic review. , 2009, Telemedicine journal and e-health : the official journal of the American Telemedicine Association.

[73]  J. Car,et al.  Mobile phone messaging for facilitating self-management of long-term illnesses. , 2012, The Cochrane database of systematic reviews.

[74]  A. Copas,et al.  Preferred options for receiving sexual health screening results: a population and patient survey , 2008, International journal of STD & AIDS.

[75]  Pamela Campanelli,et al.  Testing Survey Questions: New Directions in Cognitive Interviewing , 1997 .

[76]  R B Haynes,et al.  Can computerized clinical decision support systems improve diabetes management? A systematic review and meta‐analysis , 2013, Diabetic medicine : a journal of the British Diabetic Association.

[77]  J. Alexander,et al.  Cardiovascular risks with azithromycin and other antibacterial drugs. , 2013, The New England journal of medicine.

[78]  S. M. Rogers,et al.  Audio computer assisted interviewing to measure HIV risk behaviours in a clinic population , 2005, Sexually Transmitted Infections.

[79]  Kathleen Baldwin,et al.  The Impact of Health Education Transmitted Via Social Media or Text Messaging on Adolescent and Young Adult Risky Sexual Behavior: A Systematic Review of the Literature , 2014, Sexually transmitted diseases.

[80]  D. Rowen,et al.  Access to genitourinary medicine clinics in the United Kingdom , 2001, Sexually transmitted infections.

[81]  Suzanne Austin Boren,et al.  Computer-Aided Diabetes Education: A Synthesis of Randomized Controlled Trials , 2006, AMIA.

[82]  Susan Michie,et al.  Developing and Evaluating Complex Interventions , 2015 .

[83]  Aijing Shang,et al.  Improved effectiveness of partner notification for patients with sexually transmitted infections: systematic review , 2007, BMJ : British Medical Journal.

[84]  Anne M Johnson,et al.  Developing and testing accelerated partner therapy for partner notification for people with genital Chlamydia trachomatis diagnosed in primary care: a pilot randomised controlled trial , 2015, Sexually Transmitted Infections.

[85]  M. McFarlane,et al.  Evaluating a Web-Based Test Results System at an Urban STI Clinic , 2010, Sexually transmitted diseases.