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Customizing online education for cardiac patients

By Aleksandra Jovicic, Paul W. Smith, Mark Chignell / October 2007

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There are many opportunities for the use of online educational methods outside of settings such as schools, universities, and corporate training programs. One particularly promising area of application for online education is healthcare, where it may promote a more informed use of the healthcare system and beneficial lifestyle changes in populations affected by chronic illness. Our focus in this paper will be online training to promote beneficial lifestyle changes in the chronically ill. This population is typically elderly and with fewer computer skills. Is online education a suitable delivery method? If it is, how should it be structured? This paper describes the requirements analysis involving this patient population and the resulting design of an online educational strategy. It is anticipated that many of the issues raised in this paper should also be relevant to other online training applications. Subsequent research will assess the effectiveness of the proposed interventions.


Heart failure is characterized by high incidence and severity. It is the most common cause of hospitalization for adults over 65 (Smith, 2002), and it is estimated that more than 59 percent of men and 45 percent of women will die within 10 years of the first onset of symptoms (Levy et al, 2002). While heart failure is irreversible, lifestyle changes, such as exercise, diet, maintenance of desirable weight, and symptom monitoring are crucial for ensuring that the patient's health does not deteriorate. According to Miller's Pyramid (Miller, 1990) education is a prerequisite to behavior change. The present case study demonstrates the process of identification of appropriate educational strategy and further requirements analysis involving patients and nursing specialists. We illustrate how findings from such analysis can guide design of online educational interventions.

Systematic Review of Self-Management Interventions

As a first step towards identifying the type of education that could assist heart failure patients, we reviewed educational interventions for patients with chronic conditions of similar complexity. Previous work showed that self-management strategies-defined by Health Canada as "decisions and actions taken by someone who is facing a health problem or issue in order to cope with it and improve his or her health"-improved health outcomes for patients with chronic conditions such as diabetes and asthma (Health Canada, 2005). In order to find out whether the same was true for heart failure patients, we completed a systematic review of self-management strategies involving this patient population. Pooled results from seven randomized controlled trials identified through literature search and selection, showed that teaching heart failure patients discharged from the hospital to assume care of their health can reduce readmission and improve health behavior (Jovicic et al, 2006). Thus, it was decided to include patient self-management strategies in our educational approach.

All the studies included in the systematic review involved education about self-management, with limited telephone follow-up by a nurse. Across the studies surveyed, the greatest improvements in health outcomes were obtained by a study which utilized multiple education sessions, allowing reinforcement of educational content.

Obtaining Insider Perspective

While we wanted to incorporate successful strategies used in the systematic review studies, we did not necessarily seek to do this through a technological solution. In our requirements analysis, we merely wanted to better understand the factors that affect patients' ability to manage their condition. To accomplish this, we interviewed nurses who assist patients in transition from hospital to home, as well as heart failure patients who were discharged from the hospital (Jovicic & Straus, 2006). Both were asked about issues that patients face as they transition from hospital to home.

The nurses identified several key issues. First, patients need a range of diverse services upon discharge from hospital, such as financial assistance, home care, and rehabilitation services. But most frequently, patients need assistance with transportation. In some cases, patients were not able even to leave the hospital until transportation had been arranged, though they were considered "mobile" in general. We also learned that assistance with coordination of services, available during hospitalization and at discharge, did not remain available to patients after they had moved back into the community. Finally, since patient care is typically transferred to the patient's community-based physician, hospital follow-ups and assistance with coordination of services usually ceased once patients left the hospital, raising the likelihood of gaps in provision of care occurring.

Patient interviews provided additional insights concerning barriers and enablers of care. First, lack of mobility was an issue that affected the majority of patients, confirming nurses' observations about transportation needs. Most patients remained housebound for a number of reasons, such as shortness of breath, physical injury or frailty (most patients affected by heart failure are elderly) or fear of falling. City infrastructure was also blamed: Public spaces where one can rest were few, and washrooms do not adequately accommodate the elderly and frail. The restricted mobility resulted in fewer visits to physicians, relatives, and friends. Consequently, lack of social contact was perceived as the second most important factor influencing patients' quality of life, especially among women. Finally, most patients reported that they encountered gaps in care, such as lack of education about self-care, lack of appropriate referrals, confusion with available treatment options, and insufficient time to deal with health concerns. These comments were consistent with the fact that no coordinated care was available outside the hospital.

Design Strategies

Based on the results obtained through interviews, more specific characteristics required of the education program became apparent. In designing the intervention, we attempted to incorporate the enablers, and to address the barriers to care:

  • Since patients had reduced mobility, the training system should not require patients to leave home in order to obtain medical advice. Consequently, a remote learning approach was chosen. As discussed previously, it was decided that the educational program would include self-management strategies.
  • Since gaps in provision of care were a major theme identified through interviews, it was decided that the educational program would be led by specialist cardiac nurse.
  • The systematic review also revealed that ongoing contact with medical staff was beneficial. This led us to structure the telemonitoring intervention into multiple educational sessions. The sessions would be live rather than recorded, so that patients could ask questions about issues pertaining to heart disease.
  • Finally, it was decided that the education would involve a nurse interacting with a group of patients rather than with individual patients. Group discussion would allow patients to share strategies for coping with the illness, while also reducing the overall cost of the training intervention. The sessions were designed to start with the nurse's presentation of a health topic, and would be followed by questions, answers, and discussions of related health issues.

The design of the user interface was iterative. First, the user interface for the Vocal Village remote teleconferencing tool (Kilgore and Chignell, 2004) was adapted through a series of evaluations with users. The Vocal Village is a Voice over Internet Protocol (VOIP) conferencing application that allows high-quality voice conferencing within dispersed groups of up to ten participants. The application was extended to include streaming video from the nurse to the patients participating in the educational session. The revised application was subjected to additional user testing to ensure ease of use.

Alternative Designs

Two similar educational strategies are proposed for the evaluation. The same educational content will be delivered in two additional formats that are commonly used at present: online text (websites) and a recorded presentation.

Educational material that will form the basis for the nurse's live presentation and for the alternative methods was adopted from the Heart Failure Society of America (HFSA) website. The HFSA site contains 11 modules on heart failure, from which eight modules pertaining to self care were selected using a modified Delphi process involving doctors, nurses, and researchers.

Live education with a cardiac nurse was structured into four sessions, with each session covering content from two modules. Each of these sessions will involve 5 to 6 patients who can watch the nurse and ask questions in real time.

To minimize differences in education delivery, the recorded presentation simply involves recordings of live sessions, with nurse-patient interactions edited out. Consistent with the method in which prerecorded content is typically available online, these recordings are available for download at the convenience of patients. This format, if shown to deliver equal or better results than live educational sessions, will allow hospitals to deliver education far more efficiently and cost-efficiently than is possible at present. If the live approach is significantly better, hospitals will need to consider making the necessary investment to support that approach.

Similarly, delivering educational content through a website is quite common. A comparison with two educational methods described above will reveal whether it is an adequate substitute for nurse-led online education.

Evaluation and Data Collection

The primary goal of this study is increase patients' understanding of self-management recommendations for people living with heart failure. Knowledge will be assessed at baseline and following the intervention using a validated test of heart failure self-care knowledge. Secondary outcomes include ratings of content and method and frequency of communication per group. These ratings will be obtained upon completion of the study.

In addition, transcripts of live sessions and patients' feedback on the educational method will be analyzed in order to identify underlying themes that influence the utility of, and patients' satisfaction with, each educational method. This data includes patients' opinion of the educational content presented and experiences with adoption of the educational material into their self-care practice. These outcomes will be collected as free-text responses. Qualitative analysis based on the Grounded theory approach (Glaser & Straus, 1967) will be used to identify principal themes in participants' responses.


This paper presents a case study for designing an online training intervention around a non-traditional population of learners. First, a system review of relevant scientific literature is carried out to identify requirements and opportunities. Second, interviews with relevant stakeholders are carried out to provide further design guidance concerning the issues of most importance and how they should be addressed. Finally, an experimental study is designed to evaluate competing alternatives that cannot be disentangled based on the data previously collected. At this point in this research the detailed findings of this case study will diverge from the general properties that have been highlighted in this study and that are relevant to its role as a general case study concerning the analysis and design of online training interventions for non-traditional populations.

While further discussion of the experimental study is outside the scope of this article, it may suffice to note that comparison between the live online and recorded presentations in our healthcare application will likely tell us whether the opportunities to ask questions, hear responses to others' questions, and interact with other patients will justify the extra cost of using live interaction with a nurse. If the patients understand how to manage their care much better and significantly benefit from being part of a group, then the costlier approach may be chosen by some hospitals. The live approach may even lead to patients supporting each other after the formal education is complete.

The research-based approach to analysis and design of online training interventions is offered as a principled way to customize training to the needs of particular applications and users. It is expected that the methodology described in this case study may be usefully applied to a variety of different online training applications.


Glaser BG. and A.L.Strauss (1967) Discovery of grounded theory: The strategies for qualitative search. New York, New York: Aldine Transaction, 1967.

Health Canada: Supporting self-care: The contribution of nurses and physicians: An exploratory study. Online resource. URL: (Accessed July 2005).

Jovicic A., J.M. Holroyd-Leduc and S.E. Straus (2006) Effects of self-management intervention on health outcomes of patients with heart failure: a systematic review of randomized controlled trials. BioMed Central Cardiovascular Disorders 6:43. Online resource. URL: (Accessed January 23, 2007)

Jovicic A. and S. Straus (2006) Self-management issues of patients with heart failure: A qualitative study. In Clinical and Investigative Medicine, 29 (3).

Kilgore R. and M. Chignell (2004) The Vocal Village: enhancing collaboration with spatialized audio. In Proceedings of World Conference on E-Learning in Corporate, Government, Healthcare, and Higher Education (G Richards Ed.), pp. 2731-36, Chesapeake, VA: AACE.

Levy D., S.Kenchaiah, M.G. Larson, E.J. Benjamin, M.J. Kupka, K.K.L. Ho, J.M. Murabito, and R.S. Vasan (2002). Long term trends in the incidence of and survival with heart failure. N Eng J Med 2002, 347(18):1397-1402.

Miller, G.E. The assessment of clinical skills/competence/performance. Acad Med 1990; 65 (Suppl): S63-7

Smith, E.R. (2002). Heart failure - are we making progress? Can J Cardiology 2002, 18:1124-1125


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