Mobile health apps (MHAs) and medical apps (MAs) are becoming increasingly popular as digital interventions in a wide range of health-related applications in almost all sectors of healthcare. The surge in demand for digital medical solutions has been accelerated by the need for new diagnostic and therapeutic methods in the current coronavirus disease 2019 pandemic. This also applies to clinical practice in gastroenterology, which has, in many respects, undergone a recent digital transformation with numerous consequences that will impact patients and health care professionals in the near future. MHAs and MAs are considered to have great potential, especially for chronic diseases, as they can support the self-management of patients in many ways. Despite the great potential associated with the application of MHAs and MAs in gastroenterology and health care in general, there are numerous challenges to be met in the future, including both the ethical and legal aspects of applying this technology. The aim of this article is to provide an overview of the current status of MHA and MA use in the field of gastroenterology, describe the future perspectives in this field and point out some of the challenges that need to be addressed.

Impact of mobile health and medical applications on clinical practice in gastroenterology.

Objective: Determination of transitional readiness is an essential component of delivery of transition services to adolescents and young adults with chronic diseases, including those with inflammatory bowel disease. To date, this has been performed using the transition checklist. However, clinical experience suggests the validity of the checklist may not be ideal. We sought to evaluate the validity of the transition checklist among adolescents and young adults with inflammatory bowel disease (AYA IBD). Methods: We evaluated the validity of the transition checklist (TC) compared with a skills-based practicum (TKSP) in a cross-sectional study using a real-world clinical cohort of AYA IBD. Extent of concordance between TC and TKSP was assessed using confusion matrices and calculation of Matthews correlation coefficients. Results: Concordance between self-reported TC answers and TKSP performance varied based on skill/knowledge base assessed, ranging from 81.3% for mastery of knowing one’s medical condition to 39.2% for mastery of knowing one’s medication schedule and 29.3% for mastery of knowing how to refill medications. Matthews correlation coefficients were closer to random prediction than perfect correlation for all skills/knowledge tested. Conclusions: Self-reported TC answers lack sufficient concordance with TKSP performance. Our findings suggest that a TKSP should be performed to assess for transition readiness and to identify individual AYA IBD patient needs during the transition process. 

Evaluating Transition Readiness: Is Self-Report Valid as the Gold Standard?

Integrating transition readiness assessment into clinical practice: Adaptation of the UNC TRXANSITION index into the cerner electronic medical record.

Objective: Determination of transitional readiness is an essential component of delivery of transition services to adolescents and young adults with chronic diseases, including those with inflammatory bowel disease (IBD). To date, this has been performed using the transition checklist (TC). However, clinical experience suggests the validity of the checklist may not be ideal. We sought to evaluate the validity of the TC among adolescents and young adults with IBD (AYA IBD). Methods: We evaluated the validity of the TC compared with a skills-based practicum (TKSP) in a cross-sectional study using a real-world clinical cohort of AYA IBD. Extent of concordance between TC and TKSP was assessed using confusion matrices and calculation of Matthews correlation coefficients. Results: Concordance between self-reported TC answers and TKSP performance varied based on skill/knowledge base assessed, ranging from 81.3% for mastery of knowing one’s medical condition to 39.2% for mastery of knowing one’s medication schedule and 29.3% for mastery of knowing how to refill medications. Matthews correlation coefficients were closer to random prediction than perfect correlation for all skills/knowledge tested. Conclusions: Self-reported TC answers lack sufficient concordance with TKSP performance. Our findings suggest that a TKSP should be performed to assess for transition readiness and to identify individual AYA IBD patient needs during the transition process.

Patient Portal Usage: An Objective Target for Transition Interventions Among Youth with IBD?

Objectives The aim of the study was to evaluate feasibility and utility of an electronic health record (EHR) activity to assess transitional readiness, deliver services to meet individual needs, and to track patient progress. Methods We developed a Transition EHR activity (TEA) to track patients through a standardized process where transition readiness is annually assessed and services distributed based on need. The process assesses transition skills starting at age 12 years and sets goals through shared decision-making, delivers resources according to need, reviews patients' personal medical histories, and documents healthcare transfer to adult gastroenterology. We piloted TEA among patients with inflammatory bowel disease (IBD) ages ≥12 years. Distribution to patients was measured and tolerability assessed via patient self-report evaluations. Results Since launch, TEA has been distributed to all eligible patients (N = 53) with a median age of 16 (14,18) years (median [IQR]), 62% male, 58% white, 26% Hispanic at our weekly dedicated IBD clinic. All have performed the transition skills' self-assessment and practicum, and set transition goals with their healthcare provider. Of these individuals, 41 (77%) participated in survey feedback. On a utility rating scale of 0 (not helpful at all) to 10 (very helpful), patients reported median (IQR) utility scores of 8 (7,10) for the transition readiness assessment, 9 (7,10) for transition resources provided, and 9 (7,10) for the medical history summary. Most (91%) would recommend TEA to other patients. Conclusions TEA standardized delivery of resources among pediatric IBD patients and was well received and friendly to clinical workflow.

Harnessing the Electronic Health Record to Distribute Transition Services to Adolescents With Inflammatory Bowel Disease.

Adolescents and young adults with inflammatory bowel disease (AYA-IBD) must learn how to independently manage their disease and to communicate effectively with healthcare staff to prepare for the transfer from pediatric to adult health care. This process of transition requires time and investment from providers, patients, and healthcare systems. Despite recommendations by multiple agencies1White P.H. et al.Pediatrics. 2018; 142e20182587Crossref Scopus (271) Google Scholar,2Baldassano R. et al.J Pediatr Gastroenterol Nutr. 2002; 34: 245-248Crossref PubMed Scopus (142) Google Scholar to begin transition services at early adolescence owing to negative health outcomes and increased healthcare costs associated with a poor transition,1White P.H. et al.Pediatrics. 2018; 142e20182587Crossref Scopus (271) Google Scholar deficits in transition service delivery remain among AYA-IBD.3Department of Health/Child Health and Maternity Services BranchTransition: getting it right for young people. Improving the transition of young people with long term conditions from children's to adult health services. Department of Health, London, United Kingdom2006Google ScholarWe previously demonstrated effective delivery of transition services to AYA-IBD via an electronic health record (EHR)–enabled transition activity at our specialized inflammatory bowel disease (IBD) clinic,4Huang J.S. et al.J Pediatr Gastroenterol Nutr. 2020; 70: 200-204Crossref PubMed Scopus (4) Google Scholar including annual performance of a transition readiness assessment (a checklist and skills practicum), setting goals based on readiness assessment performance and through shared decision-making, and delivery of resources including review of patients' medical histories via personalized medical summaries. However, most AYA-IBD (∼85%) at our urban academic medical center are evaluated at general gastroenterology (GI) clinics. Similarly, not all centers can regularly cohort AYA-IBD visits within specified time frames or with select providers to deliver transition services. Therefore, methods must be developed that can incorporate transition service delivery into general GI clinic workflow.We present a single-institution, quality improvement initiative aimed at improving delivering transition services to AYA-IBD across all clinic visits. Baseline data at our institution demonstrated that 15% of eligible AYA-IBD were receiving EHR-enabled transition services on a weekly basis. Our smart aim was to improve weekly rates of AYA-IBD transition service delivery from 15% to 80% over 1 year.Setting and population. The pediatric GI division at Rady Children's Hospital provides the majority of local pediatric GI care at an urban academic center. Our service provides care to 509 youth with IBD, of whom 426 are eligible for transition services (>12 y without diagnoses associated with cognitive deficits). Our general GI clinic cares for ∼3600 patients per year via >5200 clinic visits. The clinic staff includes 19 providers, 12 nurses, and 6 medical assistants. Rady Children's Hospital uses Epic EHR systems.Our quality improvement initiative occurred from May 2020 to May 2021. Using process mapping and failure mode and effects analysis, we determined our key drivers and interventions and constructed a key driver diagram (Figure 1A ). Identified interventions are described in the following:EHR-enabled transition activity. This activity was locally programmed in Epic EHR as previously described.4Huang J.S. et al.J Pediatr Gastroenterol Nutr. 2020; 70: 200-204Crossref PubMed Scopus (4) Google Scholar Plans are underway to release this functionality across Epic EHR systems for universal usage.Improving provider awareness regarding transition. Monthly provider presentations on transition issues and the importance of transition in the care of AYA-IBD were performed. Interim progress reports on the initiative's smart aim were performed, and logistical/technical problems, addressed.Time and compensation for transition services. In response to provider care quality concerns, IBD visit durations were increased from 20 to 40 minutes to provide adequate time for disease management and annual transition service delivery. Furthermore, billing codes for additional time spent for development of the medical summary and for delivery of transition services were identified for provider use.Provider notification. Provider notification occurred in three phases: (1) via an EHR health maintenance checklist (already released system wide in Epic EHR systems5Huang J.S. et al.Inflammatory Bowel Diseases. 2020; 26: e76Crossref PubMed Scopus (0) Google Scholar) that identified whether transition services were due at the time of a given visit and automated previsit assignment of transition readiness assessments, (2) a personalized provider list of patients who were yet to receive annual transition services, and (3) weekly reminders of upcoming visits where patients were due for transition services. Provider reminders and previsit transition assessment assignment were initially manually performed but were subsequently automated via the EHR.Staff support. Staff ensured that transition readiness assessments were completed prior to the provider visit via day-before patient reminders and/or opening EHR questionnaires for patient performance at check-in. Staff provided AYA-IBD with handouts/resources based on transition goals decided during the visit, as well as the printed medical summary for review. Staff received the weekly reminders of upcoming visits where patients were due for transition services.The initiative's selected outcome was % eligible AYA-IBD who received transition services per week. We used Microsoft Excel and Quality Improvement Macros to develop statistical process control charts to examine changes in measures over time. Established rules were used for interpretation of control charts.6Provost L.P. Murray S.K. The health care data guide: learning from data for improvement.1st ed. Jossey-Bass, San Francisco, CA2011Google Scholar The centerline and control limits were revised when an intervention was associated with special cause variation, as defined by 8 consecutive points above or below the mean.Demographics of AYA-IBD are displayed in Table 1. We achieved 3 statistical process control chart shifts associated with our interventions and increased weekly transition service delivery from 15% to >90% (Figure 1B). We achieved our goal of ≥80% transition service delivery, and our final shift was sustained for 12 weeks.Table 1Demographics of AYA-IBD CohortIBD clinic registryEligible for transition servicesN509426Race (N)American Indian/Alaskan Native (1)American Indian/Alaskan Native (1)Asian Indian (1)Asian Indian (1)Black (15)Black (13)Decline to answer (3)Decline to answer (2)Multiple races (14)Multiple races (10)Other (123)Other (109)Asian/Pacific Islander (21)Asian/Pacific Islander (16)White (331)White (274)Ethnicity (N)Hispanic (134)Hispanic (114)Non-Hispanic (371)Non-Hispanic (309)Refused to answer (4)Refused to answer (3)Male : Female293:216243:183IBD diagnosis (%)70.7% Crohns70.7% Crohns22.4% Ulcerative Colitis22.3% Ulcerative Colitis6.9% IBD-Undetermined7.0% IBD-Undetermined Open table in a new tab Using quality improvement methodology, over 1 year, we increased weekly transition service delivery rates at our general GI clinic from 15% to >80% within 9 months and sustained this change for 3 months. The most substantial improvements occurred after standardizing adequate visit time, providing clinical reminders, and increasing staff support. The importance of this work is highlighted by the increasing incidence of pediatric IBD7Sýkora J. et al.World J Gastroenterol. 2018; 24: 2741-2763Crossref PubMed Scopus (143) Google Scholar (and parallel expected increase in AYA-IBD undergoing transition) and the rarity of pediatric IBD centers relative to general pediatric GI clinics, where the majority of AYA-IBD receive care.A commonly cited barrier to delivery of transition services is the lack of systematic support.8Gray W.N. et al.Inflamm Bowel Dis. 2016; 22: 372-379Crossref PubMed Scopus (30) Google Scholar The EHR has demonstrated potential to provide such support and improve care.4Huang J.S. et al.J Pediatr Gastroenterol Nutr. 2020; 70: 200-204Crossref PubMed Scopus (4) Google Scholar,9Kern L.M. et al.J Gen Intern Med. 2013; 28: 496-503Crossref PubMed Scopus (93) Google Scholar,10Manca D.P. Can Fam Physician. 2015; 61 (850–851): 846-847PubMed Google Scholar We describe a system that harnesses EHR capabilities to standardize time allotment for patient visits, to ensure transition service delivery, and to automate healthcare team previsit reminders and transition readiness assessment assignment. Additional investments required for success in the current initiative included provider education/awareness and staff support. While staff support led to substantial improvements, staff functions could potentially be automated with additional EHR programming (ie, automated patient notification to perform transition assessments).In sum, utilizing available EHR capabilities with appropriate system supports, the routine delivery of transition services can be a feasible goal for general GI centers caring for AYA-IBD. Adolescents and young adults with inflammatory bowel disease (AYA-IBD) must learn how to independently manage their disease and to communicate effectively with healthcare staff to prepare for the transfer from pediatric to adult health care. This process of transition requires time and investment from providers, patients, and healthcare systems. Despite recommendations by multiple agencies1White P.H. et al.Pediatrics. 2018; 142e20182587Crossref Scopus (271) Google Scholar,2Baldassano R. et al.J Pediatr Gastroenterol Nutr. 2002; 34: 245-248Crossref PubMed Scopus (142) Google Scholar to begin transition services at early adolescence owing to negative health outcomes and increased healthcare costs associated with a poor transition,1White P.H. et al.Pediatrics. 2018; 142e20182587Crossref Scopus (271) Google Scholar deficits in transition service delivery remain among AYA-IBD.3Department of Health/Child Health and Maternity Services BranchTransition: getting it right for young people. Improving the transition of young people with long term conditions from children's to adult health services. Department of Health, London, United Kingdom2006Google Scholar We previously demonstrated effective delivery of transition services to AYA-IBD via an electronic health record (EHR)–enabled transition activity at our specialized inflammatory bowel disease (IBD) clinic,4Huang J.S. et al.J Pediatr Gastroenterol Nutr. 2020; 70: 200-204Crossref PubMed Scopus (4) Google Scholar including annual performance of a transition readiness assessment (a checklist and skills practicum), setting goals based on readiness assessment performance and through shared decision-making, and delivery of resources including review of patients' medical histories via personalized medical summaries. However, most AYA-IBD (∼85%) at our urban academic medical center are evaluated at general gastroenterology (GI) clinics. Similarly, not all centers can regularly cohort AYA-IBD visits within specified time frames or with select providers to deliver transition services. Therefore, methods must be developed that can incorporate transition service delivery into general GI clinic workflow. We present a single-institution, quality improvement initiative aimed at improving delivering transition services to AYA-IBD across all clinic visits. Baseline data at our institution demonstrated that 15% of eligible AYA-IBD were receiving EHR-enabled transition services on a weekly basis. Our smart aim was to improve weekly rates of AYA-IBD transition service delivery from 15% to 80% over 1 year. Setting and population. The pediatric GI division at Rady Children's Hospital provides the majority of local pediatric GI care at an urban academic center. Our service provides care to 509 youth with IBD, of whom 426 are eligible for transition services (>12 y without diagnoses associated with cognitive deficits). Our general GI clinic cares for ∼3600 patients per year via >5200 clinic visits. The clinic staff includes 19 providers, 12 nurses, and 6 medical assistants. Rady Children's Hospital uses Epic EHR systems. Our quality improvement initiative occurred from May 2020 to May 2021. Using process mapping and failure mode and effects analysis, we determined our key drivers and interventions and constructed a key driver diagram (Figure 1A ). Identified interventions are described in the following: EHR-enabled transition activity. This activity was locally programmed in Epic EHR as previously described.4Huang J.S. et al.J Pediatr Gastroenterol Nutr. 2020; 70: 200-204Crossref PubMed Scopus (4) Google Scholar Plans are underway to release this functionality across Epic EHR systems for universal usage. Improving provider awareness regarding transition. Monthly provider presentations on transition issues and the importance of transition in the care of AYA-IBD were performed. Interim progress reports on the initiative's smart aim were performed, and logistical/technical problems, addressed. Time and compensation for transition services. In response to provider care quality concerns, IBD visit durations were increased from 20 to 40 minutes to provide adequate time for disease management and annual transition service delivery. Furthermore, billing codes for additional time spent for development of the medical summary and for delivery of transition services were identified for provider use. Provider notification. Provider notification occurred in three phases: (1) via an EHR health maintenance checklist (already released system wide in Epic EHR systems5Huang J.S. et al.Inflammatory Bowel Diseases. 2020; 26: e76Crossref PubMed Scopus (0) Google Scholar) that identified whether transition services were due at the time of a given visit and automated previsit assignment of transition readiness assessments, (2) a personalized provider list of patients who were yet to receive annual transition services, and (3) weekly reminders of upcoming visits where patients were due for transition services. Provider reminders and previsit transition assessment assignment were initially manually performed but were subsequently automated via the EHR. Staff support. Staff ensured that transition readiness assessments were completed prior to the provider visit via day-before patient reminders and/or opening EHR questionnaires for patient performance at check-in. Staff provided AYA-IBD with handouts/resources based on transition goals decided during the visit, as well as the printed medical summary for review. Staff received the weekly reminders of upcoming visits where patients were due for transition services. The initiative's selected outcome was % eligible AYA-IBD who received transition services per week. We used Microsoft Excel and Quality Improvement Macros to develop statistical process control charts to examine changes in measures over time. Established rules were used for interpretation of control charts.6Provost L.P. Murray S.K. The health care data guide: learning from data for improvement.1st ed. Jossey-Bass, San Francisco, CA2011Google Scholar The centerline and control limits were revised when an intervention was associated with special cause variation, as defined by 8 consecutive points above or below the mean. Demographics of AYA-IBD are displayed in Table 1. We achieved 3 statistical process control chart shifts associated with our interventions and increased weekly transition service delivery from 15% to >90% (Figure 1B). We achieved our goal of ≥80% transition service delivery, and our final shift was sustained for 12 weeks. Using quality improvement methodology, over 1 year, we increased weekly transition service delivery rates at our general GI clinic from 15% to >80% within 9 months and sustained this change for 3 months. The most substantial improvements occurred after standardizing adequate visit time, providing clinical reminders, and increasing staff support. The importance of this work is highlighted by the increasing incidence of pediatric IBD7Sýkora J. et al.World J Gastroenterol. 2018; 24: 2741-2763Crossref PubMed Scopus (143) Google Scholar (and parallel expected increase in AYA-IBD undergoing transition) and the rarity of pediatric IBD centers relative to general pediatric GI clinics, where the majority of AYA-IBD receive care. A commonly cited barrier to delivery of transition services is the lack of systematic support.8Gray W.N. et al.Inflamm Bowel Dis. 2016; 22: 372-379Crossref PubMed Scopus (30) Google Scholar The EHR has demonstrated potential to provide such support and improve care.4Huang J.S. et al.J Pediatr Gastroenterol Nutr. 2020; 70: 200-204Crossref PubMed Scopus (4) Google Scholar,9Kern L.M. et al.J Gen Intern Med. 2013; 28: 496-503Crossref PubMed Scopus (93) Google Scholar,10Manca D.P. Can Fam Physician. 2015; 61 (850–851): 846-847PubMed Google Scholar We describe a system that harnesses EHR capabilities to standardize time allotment for patient visits, to ensure transition service delivery, and to automate healthcare team previsit reminders and transition readiness assessment assignment. Additional investments required for success in the current initiative included provider education/awareness and staff support. While staff support led to substantial improvements, staff functions could potentially be automated with additional EHR programming (ie, automated patient notification to perform transition assessments). In sum, utilizing available EHR capabilities with appropriate system supports, the routine delivery of transition services can be a feasible goal for general GI centers caring for AYA-IBD. Supplementary Materials Download .docx (.02 MB) Help with docx files Supplementary Materials Download .docx (.02 MB) Help with docx files Supplementary Materials 

Enabling Transition Service Delivery in a General Gastroenterology Clinic via the Electronic Health Record and System Supports

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Harnessing the Electronic Health Record to Distribute Transition Services to Adolescents With Inflammatory Bowel Disease.

Evaluating Transition Readiness: Is Self-Report Valid as the Gold Standard?

Enabling Transition Service Delivery in a General Gastroenterology Clinic via the Electronic Health Record and System Supports