App interactions, patient-gathered data, and pre-post questionnaire responses

Eight participants completed the first questionnaire set, with five completing both questionnaire sets.

All participants provided usage-logs, which included patient-gathered data, i.e., physical activity, BG values, calories/carbohydrates, and medication (e.g., insulin, oral medication), and the number and time of interactions with the app. Two attempts were made to recruit HCP and patients. Four patients (n=1 T1D, n=3 T2D) participated in the study-end focus group meeting. One nurse participated in the corresponding healthcare personnel focus group meeting. However, this nurse did not see any of our patient-participants.

users’ perception of their patient-provider relationship and one diagram depicting the patient and HCPs’ reported experiences using the system for data-sharing during the study consultation. After each diagram, a brief text will summarize how the data was analysed to give a more complete

understanding of each of the three main impacts: i) users’ health, app-use and self-management, ii) the patient-provider relationship and iii) use of the FullFlow data-sharing system.

Use case 1: Qualitative and quantitative data related to a T2D user and his HCP T2D user’s health, app-use, and self-management

Figure 13 illustrates the variety of participants’ data, i.e., demographic and reported self-management data, usage-logs, changes in self-efficacy via the DES-SF [235], changes in reported wellbeing via the WHO-5 Wellbeing Index [236] and quotations from the focus group meeting about their use of the app for self-management. Major trends within the usage-logs are pointed out in the graph. Based on these data, we can see what parameters this individual focused on as well as begin to understand how these changed during the intervention and some explanations for why this individual chose to engage in the manner that he did and why some parameters changed. Note that HbA1c for this participant was not inputted correctly and is, therefore, missing from this dataset.

Figure 13 Quantitative and qualitative data related to T2D user’s health, app-use and self-management

This T2D user focused on measuring his blood glucose using a BG meter and oral medication to self-manage, but not goals. His motivation behind his focus on BG was reportedly to see how his lifestyle affected his BG levels. He chose not to set goals because, as he explained in the focus group meeting, he felt that goals were “unachievable” from the start. It appears that the user registered activity, BG,

and diet a few times during month #1 but showed a significant increase in his registration of BG values during month #2 and then a decrease until the BG registrations and interactions stopped after month #5. While there were no physical activity and a few diet registrations made in the app, this user explains that he exercised more and became more aware of what he ate. However, he expressed that he felt shame for eating poorly and, therefore, for example, during Christmas, would not register food. It is unclear why he performed so many more interactions at month #1, yet had few parameters

registered. However, technical difficulties may have played a role; he reported that it was too easy to delete his data, including his diet, which may explain the large number of deleted measurements (n=178) in his usage logs. By comparing questionnaires collected at the beginning and end of the study, we can see that he felt more refreshed after waking up and calm after the study (WHO-5 Wellness questionnaire) and experienced some improvement in his self-efficacy, including ways to overcome barriers and to stay motivated, with the exception of creating and accomplishing goals (DES-SF questionnaire).

Patient-provider relationship: T2D patient feedback

While the HCP responsible for meeting with this user did not attend the healthcare personnel focus group meeting, Figure 14 illustrates the patient’s report about what changed in their patient-provider relationship via the HCCQ questionnaire and more in-depth explanation of his preferences and frustrations with the HCPs shared during the focus group meeting, i.e., how and why he perceived changes in their patient-provider relationship.

Figure 14 Qualitative data from the patient related to patient-provider relationship

Based on his responses to the HCCQ, the T2D patient’s relationship with his GP did not change, except that he did perceive that his GP showed less confidence in his ability to make health changes.

Use of the FullFlow System: T2D patient and HCP feedback

Figure 15 illustrates what occurred during their use of the FullFlow data-sharing system during their consultation. The HCP reported discussing health measures with the patient as well as how they recall using the system and its effects on their clinical practice via post-consultation questionnaires. During the patient focus group meeting, this participant reported their experience with the system as well as how it was for them to share and discuss their data with their HCP and some explanation as to why these may have occurred.

Figure 15 Quantitative and qualitative data collected from the T2D patient and his HCP about his expectations and use of the FullFlow data-sharing system

The HCP reported using five of the six main pages of the system. However, he would ideally have liked to integrate the data into his EHR system. He found that he understood more about the T2D’s situation after using the system, and it allowed him to provide the T2D patient with more specific recommendations.

Use case 2: Qualitative and quantitative data related to a T1D user and his diabetes nurse T1D user’s health, app-use, and self-management

This case describes how a T1D user experienced the app, system, and relationship with his HCP during the 6-month study. Just as with the T2D user, we will explore these data to see what parameters this user-focused on as well as begin to understand how these changed during the intervention and some explanations for why this individual chose to engage in the manner that he did and why some parameters changed (Figure 16). Note that HbA1c was not input correctly and is, therefore, missing from this dataset.

Figure 16 Quantitative and qualitative data related to T1D user’s health, app-use and self-management

app, one does have to invest time to record enough data so that the app can have a useful level of information to help you decide, e.g., how many carbs were in your meal. By comparing questionnaires collected at the beginning and end of the study, we can see that he felt more refreshed after waking up and more active after the study (WHO-5 Wellbeing Scale) and experienced little change in his self-efficacy – only a decrease in his understanding of which parts of his diabetes he is dissatisfied with (DES-SF). Data was gathered for five months instead of six because data-collection and structuring was not finished for this participant by the time this analysis was performed.

Patient-provider relationship: T1D patient feedback only

As was the case with the T2D user, this patient’s HCP did not attend the healthcare personnel focus group meeting. Figure 17 illustrates the patient’s report about what he typically experienced during his consultations via the HCCQ questionnaire, how he felt during the consultation, and why.

Figure 17 Qualitative data from the T1D patient related to patient-provider relationship

The HCCQ questionnaire showed that the T1D’s relationship with his HCP worsened; he reported that the DN gave him fewer options, showed less confidence and encouragement toward the patient, and as a result, understood less about how he (the patient) felt about his health. While he did report positive experiences with his DN, because they were able to explore the data together, it was unclear which HCP he was referring to in the HCCQ, i.e., GP or DN. These negative experiences may be because, as he mentioned, the GP demonstrated little knowledge about his self-management and app use and, therefore, should rely more on the DN.

Use of FullFlow System: T1D patient and diabetes nurse feedback

Figure 18 illustrates what both expected from the system prior to their consultation vs. what they actually experienced, as well as how the system was used and perceived and what contributed to their perceptions.

Figure 18 Quantitative and qualitative data collected from the T1D patient and his diabetes nurse about their expectations and experiences.

While the T1D patient-reported gaining a better understanding of his HbA1c and BG, not feeling anxious sharing his data, and improving his focus on his disease and discussion of specific cases with his HCP, he also reported a very poor usability score for the system. Specifically, he believed the