Usage of a Technical Communication and Documentation System by Older Adults and Professionals in Multidisciplinary Home Rehabilitation

Together with curative medicine and prevention, rehabilitation is the most important pillar of the German health system [1]. However, regardless of the form of care, it is important to adapt it to the needs and abilities of the respective target group. This applies in particular to the field of geriatrics, in which older patients are characterized on the one hand by the presence of several chronic diseases, some of which are interdependent and influential, and on the other hand by the “normal” aging process to be expected in their performance with limitations in functional and cognitive capacity as well as mobility and perceptive faculty [2].

Mobile Home Rehabilitation (MHR) is a concept of outpatient health care in Germany. A multidisciplinary team consisting of medical doctors, therapists, social workers, psychologists and nursing staff is responsible for the treatment process of patients with severe conditions. The rehabilitation takes place in the patient’s home environment with a duration of six to eight weeks and approximately 40 therapeutic sessions. In MHR, the decentralized working methods of the various occupational groups involved mean that there is a high level of coordination and communication effort both for these groups themselves and for the patients and their relatives. For therapists working in rehabilitation, documentation of the therapy content is often difficult due to a lack of infrastructure (e.g., documentation must be completed in the car or at home) and leads to a correspondingly high documentation effort. In addition, agreements between colleagues are just as difficult as passing on relevant information. On the organizational level, both the planning of the daily routines themselves and their necessary adaptation due to current events is associated with a high level of effort.

For this reason, the Morecare project, funded by the Federal Ministry of Education and Research (2016–2018), merged various technologies into a comprehensive concept in order to work on the identified problems and to enable a more effective and sustainable working method for all actors. At the beginning of the project, the addressed barriers were specified within a requirements analysis and technical solutions were accordingly designed [3]. The aim of the applied technologies was to simplify the rehabilitation process and make it more comprehensible for patients, thus strengthening patient autonomy and the ability for successful self-management. Within an evaluation of the developed Morecare system, the following research question should be answered:

• How is a technical assistance system used and accepted by patients and therapists in mobile rehabilitation?

• How are skills in handling mobile devices changing?

To answer these questions, a study was conducted with two different groups of participants:

1. (1)

   Mobile Rehabilitation Team: 10 employees of a MRT tested the Morecare system for seven months.

2. (2)

   Older Adults (OA): 10 older adults aged ≥ 65 years evaluated the Morecare patient system for two weeks.

The methodology and results described below are presented for each of these two groups.

3.1 Developed System

Within the project, a system was created from various components:

1. (1)

   Tablet application, which supports the MRT in organizing appointments and communicating with each other as well as with patients and enables digital documentation.

2. (2)

   Patient System consisting of a tablet application for the coordination of appointments or communication with the MRT and with the possibility of conducting training sessions independently at home. The patient system was supplemented by a modular notification and operating system, which consists of Flic buttons for simplified operation of the tablet, Hue lamps for visual display of new notifications and a sensor wristband, which raises the number of steps of the patient and vibrates upon receipt of a notification (Fig. 1).

   

   Constituent parts of the modular notification and operating system: Hue lamps, sensor wristband, flic buttons

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3. (3)

   Web interface for the coordinator of the Mobile Rehabilitation, which enables the setting of appointments for the therapy sessions and communication with the MRT and patients.

4. (4)

   Vital data sensor for recording oxygen saturation, pulse and number of steps during therapy units.

3.2 Procedure

Mobile Rehabilitation Team.

The evaluation of the Morecare system by the MRT was undertaken over a period of seven months divided into two phases (Figs. 2, 3).

Procedure and questionnaires for the MRT

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On the first study visit (V1), the MRTs’ technical experience and technology commitment as well as their knowledge of the handling of mobile devices (Mobile Device Proficiency Scale, MDPQ-16, [4]) were assessed. In addition, there was extensive training on the system, in which all areas of the application were explained by the study staff. Therapists, caregivers, social workers, doctors and the coordinator then used the system for a total of seven months. In the first five months there were still fundamental changes to the application, which resulted from the requirements of the MRT. A total of 27 new versions of the application were released during these five months, in which several changes were made. After five months of testing, an interim study visit (V2) was carried out again to assess the knowledge of how to use mobile devices and the previous use and evaluation of the application using a questionnaire. Subsequently, the MRT used the Morecare system for another two months, during which no more changes were made to the application. After this period, the third study visit (V3) took place, in which the users were asked about their mobile devices proficiency as well as about the use, acceptance and usability (System Usability Scale, SUS, [5]) of the Morecare system.

Older Adults (OA).

The OA tested the Morecare system for two weeks. The two study visits were carried out by study staff in the participants’ homes. At the first study visit (V1), participants’ sociodemographic data, use of technology and the technology commitment as well as their knowledge in handling mobile end devices (MDPQ-16) were assessed. Subsequently, the Morecare system was set up in the homes of the study participants who were trained in the different components and functions. After two weeks’ system usage, the participants were again asked about their knowledge of mobile devices. In addition, a questionnaire was issued to subjectively assess the usability of the technical system and various questions were asked about the acceptance, use and user-friendliness of specific system functions and components (Fig. 3).

Procedure and questionnaires for OA

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4.1 Sample

Mobile Rehabilitation Team (MRT).

A total of 10 members of the team took part in the three survey stages (V1, V2, V3). Physiotherapists formed the largest group in the MRT. Most of the respondents were female (Table 1).

All respondents of the MRT indicated they use the Internet frequently. Computers, smartphones and telephones were frequently used by the majority of respondents. A tablet had not previously been used by two people at the beginning of the study. On the scale ranging from one to five for technical commitment (one = low TC, five = high TC) the respondents of the MRT achieved a mean value of 3.7. This corresponds to the norm values of the validation study by Neyer et al. [6] in which 825 subjects aged 18–80 years were included (M = 3.73).

Older Adults (OA).

A total of 10 participants were included in the evaluation of the Morecare patient system. The mean age of the participants was 72.5 years (range: 66–76 years). During the recruitment process, attention was taken to ensure that an equal proportion of men and women were included in the study (Table 2).

The study group of OA was also examined with regard to their technical commitment. On average, the group achieved a value of M = 3.9, which, in accordance with the standard values mentioned, indicates a high level of technical commitment.

4.2 Mobile Device Proficiency

Mobile Rehabilitation Team (MRT).

The mobile device proficiency was assessed at the three study visits with the help of the Mobile Device Proficiency Questionnaire (MDPQ-16). On average, the skills of the respondents increased during the course of the study. Overall, the score increased from 31.0 (16.5–38.5) to 33.3 (27.0–40.0) points with the duration of tablet use. The score increased by 0.2–0.85 points especially in the subscales basics, internet, entertainment, privacy and troubleshooting (Table 3).

Older Adults (OA).

Knowledge on the handling of mobile devices was collected both at the beginning and at the end of the study of the OA by completion of the MDPQ. Overall, the skills of the respondents increased slightly on average during the course of the study. The total value increased from 27.7 (11.0–39.5) to 28.6 (15.0–40.0) points. Particularly in the subscales for basics and internet, the scale averages increased by 0.6–0.65 points. At the same time, the scale averages in the subscales communication and calendar fell by 0.2–0.4 points at the end of the study (Table 4).

4.3 Usage of the System

Mobile Rehabilitation Team (MRT).

For the sake of clarity, only the frequency of use at the end of the study is presented here, but not the results of V2. Almost all respondents stated that they used the Morecare system frequently. Therapy documentation was cited as the most frequently used function. In addition, at least half of the participants used the patient file, the daily overview and the possibility to view appointments. Three functions were not used by any of the participants (Fig. 4).

Use of the individual functions of the Morecare system by the MRT, V3 (N = 10). Note: The five points of the questionnaire answer scale were grouped into three categories to improve clarity: “daily” and “several times a week” = frequently; “once a week” and “<once a week” = occasionally; “never” = never.

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Older Adults (OA).

With regard to the frequency of use, four of the 10 study participants stated that they used the Morecare application (almost) daily. The remaining six participants used it several times a week. When considering the frequency of use of the individual functions of the Morecare application, the ability to review the activity data was used most frequently. Participants also frequently used the areas of self-exercise and appointment overview as well as the control of the system via flic buttons. Two study participants occasionally used the help function (Fig. 5).

Use of the individual functions of the Morecare system, OA, V2 (N = 10). Note: The five points of the questionnaire answer scale were grouped into three categories to improve clarity: “daily” and “several times a week” = frequently; “once a week” and “<once a week” = occasionally; “never” = never.

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4.4 Evaluation of the Morecare System

Mobile Rehabilitation Team (MRT).

The MRT was asked how they value the various functions in the app. Of the functions used, the therapy documentation was rated as best. Six out of eight users rated the patient file as “good” or “very good”. In addition, six participants rated the daily overview “good” or “very good” (Fig. 6).

Rating of the different features by the MRT (N = 10)

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With regard to the evaluation of user-friendliness using the system usability scale, the rating were very divergent. On average, the app was given 53.25 (25.0–82.5 points) rating points, which corresponds to a low level of user friendliness.

Older Adults (OA).

Within the evaluation of the individual functions of the Morecare system, it can be stated that these were predominantly rated “very good” or “good” by the OA. The participants liked the ability to view activity data and appointments the most. In contrast, more than half of the participants did not use the help function available within the tablet application (Fig. 7).

Rating of the different features by OA (N = 10)

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Compared to the team, the seniors rated the usability of the system slightly better. On average, the app was given 63.0 (45.0–85.0 points) rating points, which corresponds to a moderate level of user friendliness.

The present study examined the use and acceptance of a technical assistance system in mobile rehabilitation. For this purpose, the system was tested by employees of a mobile rehabilitation team and by elderly people. It was shown that although the system was used regularly by the majority of the respondents, not all functions were used by both MRT and OA. In particular, the help function was hardly used by either user group. One reason for this could be the poorly rated usability of the system. In order to improve usability and acceptance as well as to increase the use of the system, it must be geared even more strongly to the needs of the target group. For example, not all previously integrated functions are necessary for the MRT, but the employees would like to integrate other functions that would make everyday work easier.

The results of this study provide valuable insights into the ability of older and functionally limited people to use and accept modern technologies. This is particularly important because the technical progress currently being observed in care and therapy can lead in the medium term to a selection based on individual knowledge and acceptance of these technologies. This is to be judged negatively in so far as a lack of acceptance on the part of the patients leads to a new group of affected persons who cannot be adequately rehabilitated and thus the dependence on care and everyday life is increased. On the other hand, on the part of care and therapy professionals, a negative attitude towards new technologies can contribute to making the profession less attractive and thus increase the existing shortage of available labor. Both these possible developments must be counteracted as far as possible during the development of such technologies.