Background: Type 2 diabetes (T2D) tremendously affects patient health and health care globally. Changing lifestyle behaviors can help curb the burden of T2D. However, health behavior change is a complex interplay of medical, behavioral, and psychological factors. Personalized lifestyle advice and promotion of self-management can help patients change their health behavior and improve glucose regulation. Digital tools are effective in areas of self-management and have great potential to support patient self-management due to low costs, 24/7 availability, and the option of dynamic automated feedback. To develop successful eHealth solutions, it is important to include stakeholders throughout the development and use a structured approach to guide the development team in planning, coordinating, and executing the development process. Objective: The aim of this study is to develop an integrated, eHealth-supported, educational care pathway for patients with T2D. Methods: The educational care pathway was developed using the first 3 phases of the Center for eHealth and Wellbeing Research roadmap: the contextual inquiry, the value specification, and the design phase. Following this roadmap, we used a scoping review about diabetes self-management education and eHealth, past experiences of eHealth practices in our hospital, focus groups with health care professionals (HCPs), and a patient panel to develop a prototype of an educational care pathway. This care pathway is called the Diabetes Box (Leiden University Medical Center) and consists of personalized education, digital educational material, self-measurements of glucose, blood pressure, activity, and sleep, and a smartphone app to bring it all together. Results: The scoping review highlights the importance of self-management education and the potential of telemonitoring and mobile apps for blood glucose regulation in patients with T2D. Focus groups with HCPs revealed the importance of including all relevant lifestyle factors, using a tailored approach, and using digital consultations. The contextual inquiry led to a set of values that stakeholders found important to include in the educational care pathway. All values were specified in biweekly meetings with key stakeholders, and a prototype was designed. This prototype was evaluated in a patient panel that revealed an overall positive impression of the care pathway but stressed that the number of apps should be restricted to one, that there should be no delay in glucose value visualization, and that insulin use should be incorporated into the app. Both patients and HCPs stressed the importance of direct automated feedback in the Diabetes Box. Conclusions: After developing the Diabetes Box prototype using the Center for eHealth and Wellbeing Research roadmap, all stakeholders believe that the concept of the Diabetes Box is useful and feasible and that direct automated feedback and education on stress and sleep are essential. A pilot study is planned to assess feasibility, acceptability, and usefulness in more detail.

@en

eHealth development faces the challenge of generating evidence about health effectiveness in real-world settings. Designers can potentially support this challenge but must understand health approaches to evidence generation about health outcomes. This case study investigates how health and care professionals conceptualise health outcomes and their evidence generation in eHealth. Our results identify three key conceptual dimensions: effect, meaning, and collection. We discuss how these inform future design competencies to support evidence generation about health outcomes in eHealth design.@en

Challenges in implementing digital health in clinical practice hinder its potential. The complexities posed by implementation could benefit from using design practices. To explore the current role of design practices in digital health implementation, designers in the Netherlands were interviewed. The preliminary results indicate that designers contribute to digital health implementation processes, especially in the early stages. Design practices are mainly used for engaging the users, testing concepts, aligning the ideas of stakeholders, and adapting interventions to fit within the contexts.

@en

This research explores the dynamic nature of family involvement in remote patient management for cardiovascular disease and its impact on lifestyle behaviour changes. Through an interview study with patients and family members, we categorise family involvement into three types: Inform, Integrate, and Influence, highlighting the dynamic and heterogeneous nature of family involvement across different phases and activities. Overall, we emphasise the need for personalised and adaptable interventions to cater to the diversity of families and propose a modular approach to remote monitoring design.@en

Background:
Patient and staff experience is a vital factor to consider in the evaluation of remote patient monitoring (RPM) interventions. However, no comprehensive overview of available RPM patient and staff experience–measuring methods and tools exists.

Objective:
This review aimed at obtaining a comprehensive set of experience constructs and corresponding measuring instruments used in contemporary RPM research and at proposing an initial set of guidelines for improving methodological standardization in this domain.

Methods:
Full-text papers reporting on instances of patient or staff experience measuring in RPM interventions, written in English, and published after January 1, 2011, were considered for eligibility. By “RPM interventions,” we referred to interventions including sensor-based patient monitoring used for clinical decision-making; papers reporting on other kinds of interventions were therefore excluded. Papers describing primary care interventions, involving participants under 18 years of age, or focusing on attitudes or technologies rather than specific interventions were also excluded. We searched 2 electronic databases, Medline (PubMed) and EMBASE, on February 12, 2021.We explored and structured the obtained corpus of data through correspondence analysis, a multivariate statistical technique.

Results:
In total, 158 papers were included, covering RPM interventions in a variety of domains. From these studies, we reported 546 experience-measuring instances in RPM, covering the use of 160 unique experience-measuring instruments to measure 120 unique experience constructs. We found that the research landscape has seen a sizeable growth in the past decade, that it is affected by a relative lack of focus on the experience of staff, and that the overall corpus of collected experience measures can be organized in 4 main categories (service system related, care related, usage and adherence related, and health outcome related). In the light of the collected findings, we provided a set of 6 actionable recommendations to RPM patient and staff experience evaluators, in terms of both what to measure and how to measure it. Overall, we suggested that RPM researchers and practitioners include experience measuring as part of integrated, interdisciplinary data strategies for continuous RPM evaluation.

Conclusions:
At present, there is a lack of consensus and standardization in the methods used to measure patient and staff experience in RPM, leading to a critical knowledge gap in our understanding of the impact of RPM interventions. This review offers targeted support for RPM experience evaluators by providing a structured, comprehensive overview of contemporary patient and staff experience measures and a set of practical guidelines for improving research quality and standardization in this domain.@en

Evidence-based practices play an essential role in the development of eHealth systems. Prior research has investigated the challenge of shared understanding between professionals from the fields of health sciences and design and has highlighted the need for effective alignment of development and research practices in eHealth. However, there is a limited understanding of epistemological differences between these fields and how professionals conceptualise evidence. In this paper, we investigate how healthcare and design professionals think about evidence and how they implement evidence practices in their work. We interviewed eight professionals and used reflexive thematic analysis to identify the challenges and strategies associated with their evidence practices. Our results identify five shared evidence practices between healthcare and design professionals: stakeholder-driven, process-driven, problem-driven, effect-driven, and solution-driven. These five evidence practices indicate opportunities for closer alignment of development and research practices among healthcare and design professionals and offer a basis to create a shared understanding of evidence between both fields.@en

Digital health technologies, powered by digital data, provide an opportunity to improve the efficacy and efficiency of health systems at large. However, little is known about different approaches to the use of data for digital health design, or about their possible relations to system-level dynamics. In this contribution, we identify four existing approaches to the use of data for digital health design, namely the silent, the overt, the data-enabled, and the convergent. After characterising the approaches, we provide real-life examples of each. Furthermore, we compare the approaches in terms of selected desirable characteristics of the design process, highlighting relative advantages and disadvantages. Finally, we reflect on the system-level relevance of the differentiation between the approaches and point towards future research directions. Overall, the contribution provides researchers and practitioners with a broad conceptual framework to examine data-related challenges and opportunities in digital health design.

@en

Designers are increasingly collaborating with data scientists to apply smart data technologies to understand large-scale user behavior during their design research. This is useful in specific impact domains with vulnerable users and unfamiliar contexts, such as healthcare design. Patient journey mapping is the most common design tool for developing and communicating patient-centred perspectives in healthcare design. However, creating a traditional patient journey map is labor intensive. Consequently, they often represent the experiences of a limited number of patients and, therefore, have limitations in including an extensive group patient experience. To overcome these challenges, we present a new data-driven and hybrid intelligent design approach that utilizes tens of thousands of online patient stories and machine-learning techniques through collaboration with data scientists. We set up two studies in the field of oncology and demonstrate that combining the two machine-learning techniques allows for quantifying the experiences of a wide range of patients, detecting relationships between co-occurring experiences within the journey, and detecting new design opportunities/directions. In these studies, designers gained a large-scale, yet qualitative and inspiring, understanding of a complex context in healthcare with reduced time and cost investments@en

This paper unpacks how actors navigate the multiple organizational, interorganizational and industry contexts that are associated with system transformation programs for addressing wicked, societal problems. Because system transformation programs can only succeed when changes are implemented by multiple organizations, an increased understanding of integrating programs in multiple contexts is needed. We draw on a qualitative field study of an interorganizational program designed to help transform the Dutch healthcare system. We identified three practices of context navigation that actors used to integrate the program into multiple parent organizations and address emerging incongruencies among contexts. These are aligning contexts, prioritizing contexts, and adding contexts. Over time, these navigating practices promoted progress towards program objectives via multiple parallel collaborative paths. Our findings shed new light on the role of breakdowns and decoupled collaborative paths in programs oriented at contributing to system transformation.

@en

Background: Remote patient monitoring (RPM) interventions are being increasingly implemented in health care environments, given their benefits for different stakeholders. However, the effects of these interventions on the workflow of clinical staff are not always considered in RPM research and practice. Objective: This review explored how contemporary RPM interventions affect clinical staff and their workflows in perioperative settings. Methods: We conducted a scoping review of recent articles reporting the impact of RPM interventions implemented in perioperative settings on clinical staff and their workflow. The databases accessed were Embase and PubMed. A qualitative analysis was performed to identify the main problems and advantages that RPM brings to staff, in addition to the approaches taken to evaluate the impact of those interventions. Different themes were identified in terms of the challenges of RPM for clinical staff as well as in terms of benefits, risk-reduction strategies, and methods for measuring the impact of these interventions on the workflow of clinical staff. Results: A total of 1063 papers were found during the initial search, of which 21 (1.98%) met the inclusion criteria. Of the 21 included papers, 15 (71%) focused on evaluating new RPM systems, 4 (19%) focused on existing systems, and 2 (10%) were reviews. Conclusions: The reviewed literature shows that the impact on staff work experience is a crucial factor to consider when developing and implementing RPM interventions in perioperative settings. However, we noticed both underdevelopment and lack of standardization in the methods for assessing the impact of these interventions on clinical staff and their workflow. On the basis of the reviewed literature, we recommend the development of more robust methods for evaluating the impact of RPM interventions on staff experience in perioperative care; the adoption of a stronger focus on transition management when introducing these interventions in clinical practice; and the inclusion of longer periods of assessment, including the evaluation of long-term goals.

@en

To unravel the complex challenges addressed by design, oftentimes it can be
necessary for researchers to participate in design processes rather than make
observations from outside. However, ‘participation’ has different meanings in
different kinds of design research, and research outcomes will depend on the
form of participation chosen. Through a Dimensional Analysis, we establish
seven dimensions on how participation in design research can be classified in
terms of 1) the researcher-designer role, 2) the aim of the project, 3) the main
contribution, 4) the activities of the researcher, 5) if it is a single or multi-case
study, 6) the scientific reporting on the project, and 7) the kind of knowledge
produced. This overview aims to assist researchers in communicating how
choices for a particular participatory approach contribute to knowledge
production in design research.@en

In this study, we envision engineering design activities for collective computing, an upcoming era of complex systems of massive social interaction through a wide variety of connected computing devices. A literature review reveals how collective computing, compared to the previous eras of personal and ubiquitous computing, may lead to new design tasks and design processes, as well as new roles for designers. Based on this review, new design activities for the collective computing era are envisioned, and further revised in an interview study with 24 informants. The result is a vision for design in the collective computing era, with actionable guidance for designers in terms of a coherent set of new design activities proposed in relation to advances in computing.

@en

One of the essential aspects of a company's design is its source of competitive advantage. Extrapolating from Raymond Loewy's famous design strategy acronym, MAYA—the Most Advanced Yet Acceptable Principle—and treating the firm as the object of design, this article explains the competitive advantage of firms from a design perspective. Our design-based recommendation for the competitive advantage of firms is to focus on shaping heterogeneity-based advantages of the firm in ways its paying customers would deem valuable. The novelty and conventionality dynamics of its industry will influence the degree of heterogeneity of the firm. Firms can shape their heterogeneity-based advantages through policies relating to organizational structure, routines, and product portfolio to name a few. Going beyond the role of a design in creating rents above and beyond what other firms can imagine, our claim focuses on the ways in which heterogeneity is a fundamental driver of its competitive advantage. If correct, the design-based view suggests that the ideal level of heterogeneity of the firm relative to current competitive conditions and evolution paths adopted by the firm and its competitors is more fundamental to firm profitability than its resources.

@en

This contribution explores the potential of lead user research for early-stage designing for intelligent ecosystems through a literature review and a single case study concerning a lead user research initiative on blood pressure monitoring. The results suggest advantages of executing lead user research in early-stage designing for intelligent ecosystems from the points of view envisioning broad initial ecosystem boundaries, developing first intelligence components, and overcoming research challenges related to technical issues.@en

Professional Identity (PI) is a social- and self-perceptive construct that describes how people understand themselves as professionals. PI guides professional development by shaping professionalism, role assumptions, responsibilities, values, and behaviour; and is a critical factor in professional performance and wellbeing. As such, PI has significant implications for how we support engineering designers in professional development and direct their social- and self-understanding. However, no current research provides a complete picture of PI elements important for Designers’ Professional Identity (DPI). This study aims to review and synthesise PI elements, currently discussed separately in the design literature, in order to propose a holistic understanding of DPI. Based on an extensive literature review, we find that DPI consists of two distinct sets of elements: Personal Attributes (PA) and Design Skills (DS). We present these two sets of elements in terms of meaning, possible relations between them, and their influence on DPI development. In addition, we propose multiple directions for future research.

@en

This paper investigates different roles that prototypes play during the development of digital Product Service Systems (PSSs). A literature review reveals that prototyping supports designers during the design process, as well as during knowledge sharing processes with stakeholders. To create a better understanding of these two co-existing roles of prototyping, we executed a research-through-design project in the healthcare domain. This design project was centred around the development of four different prototypes that the designer sequentially developed. A major input into the design process was co-reflection sessions between the designer and different stakeholders. We analysed the prototyping process and the co-reflection sessions. Moreover, we executed a conversational analysis to understand the actual knowledge sharing processes between the designer and the different stakeholders. The results present a detailed overview of the different (co-existing) roles of the prototypes. We distinguished two new types of prototypes which were both related to the development of the intangible aspects of the digital PSS: (1) service interface prototrial aimed at exploring several options for detailing the different intangible aspects of the digital PSS, and (2) service provotype to stimulate collaborative creation of the intangible aspects of the digital PSS in an early stage.

@en

This paper proposes a categorization of existing approaches to healthcare-related engineering design based on systems thinking principles. Three existing approaches to healthcare-related engineering design are isolated which contribute differently to health systems fundamental purposes and interconnections. The three approaches are labeled as 'silent', 'overt', and 'convergent' health design. Each approach is defined and illustrated through an example. Following, practical advantages and disadvantages of each approach are discussed. A reflection is offered on the expected relevance of the convergent health design approach for present and future societal challenges in the health domain, and specifically on the recently growing field of e-health. Finally, open methodological challenges related to convergent health design are outlined and characterized as opportunities for future research.@en

Within the third wave of digital service innovation, framing is becoming increasingly complex. Accordingly, design practice finds itself in a transition from designing single service solutions that are shared, to designing systemic solutions that are shareable. We report a case study in which we use Cultural Historical Activity Theory (CHAT) to analyze the framing process that a designer went through when designing a digital service for a Connected Care startup. Results show the importance of the designer’s activity awareness and the challenge of dealing with relational complexity when framing the digital service innovation. With this work, we hope to inspire researchers and practitioners with the potential that CHAT has to offer for the reflective practice in digital service innovations.@en