This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.
Cardiac and major vascular surgeries are common surgical procedures associated with high rates of postsurgical complications and related hospital readmission. In-hospital remote automated monitoring (RAM) and virtual hospital-to-home patient care systems have major potential to improve patient outcomes following cardiac and major vascular surgery. However, the science of deploying and evaluating these systems is complex and subject to risk of implementation failure.
As a precursor to a randomized controlled trial (RCT), this user testing study aimed to examine user performance and acceptance of a RAM and virtual hospital-to-home care intervention, using Philip’s Guardian and Electronic Transition to Ambulatory Care (eTrAC) technologies, respectively.
Nurses and patients participated in systems training and individual case-based user testing at two participating sites in Canada and the United Kingdom. Participants were video recorded and asked to think aloud while completing required user tasks and while being rated on user performance. Feedback was also solicited about the user experience, including user satisfaction and acceptance, through use of the Net Promoter Scale (NPS) survey and debrief interviews.
A total of 37 participants (26 nurses and 11 patients) completed user testing. The majority of nurse and patient participants were able to complete most required tasks independently, demonstrating comprehension and retention of required Guardian and eTrAC system workflows. Tasks which required additional prompting by the facilitator, for some, were related to the use of system features that enable continuous transmission of patient vital signs (eg, pairing wireless sensors to the patient) and assigning remote patient monitoring protocols. NPS scores by user group (nurses using Guardian: mean 8.8, SD 0.89; nurses using eTrAC: mean 7.7, SD 1.4; patients using eTrAC: mean 9.2, SD 0.75), overall NPS scores, and participant debrief interviews indicated nurse and patient satisfaction and acceptance of the Guardian and eTrAC systems. Both user groups stressed the need for additional opportunities to practice in order to become comfortable and proficient in the use of these systems.
User testing indicated a high degree of user acceptance of Philips’ Guardian and eTrAC systems among nurses and patients. Key insights were provided that informed refinement of clinical workflow training and systems implementation. These results were used to optimize workflows before the launch of an international RCT of in-hospital RAM and virtual hospital-to-home care for patients undergoing cardiac and major vascular surgery.
Cardiac and major vascular surgeries are common surgical procedures associated with high rates of postsurgical complications and related hospital readmission [
A factor contributing to high postsurgical complications and readmission rates following cardiac and major vascular surgeries is inadequacy of current systems for patient monitoring in hospital and at home [
The problem is further compounded once patients are discharged home without surveillance or health professional support—a significant number of patients sustain complications that their surgical teams are unaware of. A prospective study (N=328) in the United Kingdom found that 28% of cardiac surgery patients required urgent physician or district nurse intervention within the first 6 weeks of recovery at home [
Increasing efforts are being made to implement postoperative remote automated monitoring (RAM) and surveillance systems to improve patient outcomes through facilitation of continuous patient monitoring, early detection of deterioration, and remote patient support [
RAM surveillance systems have major potential, but the science of implementing and evaluating these systems is complex and still at an early stage [
Our team is conducting a randomized controlled trial (RCT) of a RAM and virtual hospital-to-home intervention entitled, TecHnology-Enabled remote monitoring and Self-MAnagemenT—VIsion for patient EmpoWerment following Cardiac and major VasculaR surgery (THE SMArTVIEW, CoVeRed) [
The current RCT (N=800) [
Recognizing that implementation of RAM represents a change to typical postoperative care [
This user testing study (and the subsequent SMArTVIEW trial) was in response to a call for applications to the Canadian Institutes of Health Research eHealth Innovation Partnerships program. This funding opportunity was designed to facilitate experimental,
Our aim was to implement an end-to-end solution that incorporates both RAM in hospital and virtual hospital-to-home recovery support for the first 30 days at home, following cardiac and major vascular surgery. Although multiple vendors came forward with various solutions, Philips was in a position to provide market-ready, configurable technology solutions for both hospital RAM and hospital-to-home virtual care that could be packaged together in an
On the surgical ward, RAM is supported by the Philips Guardian solution as illustrated in
The Philips Guardian Solution. (A) MP5 spot-check monitor, (B) wireless blood pressure monitor, (C) wireless continuous pulse oximetry monitor, and (D) wireless respiratory sensor. Reproduced with permission from Philips Canada (Markham, ON) (reprinted with copyright permission from the publisher).
Hospital-to-home remote monitoring and virtual care is supported by the Philips Electronic Transition to Ambulatory Care (eTrAC) Program as shown in
The Philips electronic Transition to Ambulatory Care system, featuring tablet interface and Bluetooth-enabled vital signs monitors. Reproduced with permission from Philips (reprinted with copyright permission from the publisher).
Our approach to Guardian and eTrAC system usability testing was guided by Wiklund et al’s
Participants included surgical ward nurses and patients recovering from cardiac or major vascular surgery. This study was conducted at two hospital sites, one in Ontario, Canada, and one in Liverpool, the United Kingdom. Nurse participants were recruited through brief presentations at staff meetings and nursing rounds, as well as through emails sent by ward managers. Nurses were invited to participate in either Guardian or eTrAC user testing, but not both, to avoid possible confounding influences of cross-system testing. Patients were invited to participate in eTrAC user testing only, given that Philips’ Guardian system does not involve active workflows for patients wearing the wireless sensors. Included patients were ambulatory, recovering from a cardiac or major vascular surgery, and were able to read, speak, and understand English. Patients who exhibited signs of postoperative delirium (via confusion assessment method) were excluded. The research personnel identified and approached eligible nurses and patients to participate in the study, obtained informed consent, collected baseline demographic information, and scheduled user testing sessions.
To account for site differences, we aimed to recruit a minimum of 6 participants per site for each system-related user test, for a total of 12 nurses for Guardian testing, 12 nurses for eTrAC testing, and 12 patients for eTrAC testing. Our total sample size of 36 participants was informed by Wiklund et al’s guidance [
The Hamilton Integrated Research Ethics Board approved the study (project reference number 2332). For the UK arm of the study, Coventry University Ethics Committee granted the ethical approval (project reference ID P50671). Research Governance approval was also granted by Dr Jay Wright, Liverpool Heart and Chest Hospital National Health Service Foundation Trust Research Committee as a Chairman’s action.
Usability testing of Guardian and eTrAC systems was conducted in two stages: hands-on systems training (Stage 1), followed by individual user testing (Stage 2;
Nurse and patient user testing workflow diagram.
Nurse participants were oriented to Guardian and eTrAC systems during half-day group training sessions. These sessions included a combination of didactic and hands-on learning activities to contextualize and apply content. Topics included nurse and patient onboarding, system navigation, device management, monitoring functions, and technical troubleshooting and related communication. At the end of each session, nurse participants received system user guides for their review and ongoing reference. Nurse participants were asked to review these guides in preparation for their individual usability testing sessions.
Participating patients received individualized, 1-hour training sessions on the eTrAC system, also featuring didactic and hands-on learning. These sessions focused on daily use of the tablet and vital signs equipment and communicating with a nurse remotely via a secure video link. The training took place at a time convenient to the patient that did not interfere with their routine care. An eTrAC user guide was also provided.
Following the systems training sessions, nurse participants took part in a 2-hour, individual, usability-testing session for either the Guardian or eTrAC system. The test activities were completed within the context of a simulation featuring one of two patient-cases, depending on nursing area of specialty—cardiac surgery (coronary artery bypass graft) or major vascular surgery (femoropopliteal bypass). Patient cases spanned postoperative days 1 through 4 and featured vital signs–related deteriorations that were programmed into the system remotely; the actors’ true vital signs were concealed. These cases were created based on real patient data by staff surgeons, residents, and nurses with minimum 5 years’ experience in managing patient deterioration at our study sites. The case scenarios were written in collaboration with the McMaster Standardized Patient Program, Centre for Simulation-Based Learning. A standard template was used to clarify required nurse end-user tasks, the setup of the simulation, and details of the patient cases including surgical details, past medical history, social and family history, and patient-related thoughts, feelings, and concerns that are common in the immediate postcardiac and postvascular surgery context. To provide a high degree of realism, 2 standardized patient actors were trained to portray each case; these actors were placed in an extra bed on the surgical unit at each site, in a separate area designated for the user testing [
Following an introduction and review of the system, nurse participants completed the test activities, which represent core nursing competencies for Guardian use including start up, use of the MP5 spot-check monitor and wireless devices, ongoing monitoring and responding to patient deterioration, and technical trouble shooting and system maintenance.
The research assistant moderated the simulation by introducing the background information on the patient and providing instructions and cues to indicate advances in case timelines (eg, “It is now postop day 3 and you return to the unit and reassess your patient.”). The actors were trained to interact with the nurse participants to add realistic distractions and stressors similar to real-world working conditions on the surgical unit.
The eTrAC user testing followed procedures similar to the Guardian user testing with hospital-to-home patient cases. The eTrAC system was programmed to display simulated patient details, changes in vital signs, and related patient notifications programmed into the system. Patient cases (cardiac and vascular surgery) spanned postdischarge days 1 through 5 and featured vital signs–related deteriorations (eg, high temperature), indicative of common postoperative adverse events (eg, infection) while recovering at home. The research assistant prompted participants with details of these cases as they unfolded to indicate the passage of time and recovery-related circumstances for the patient at home.
The patient eTrAC user testing focused on completing system tasks required for using the eTrAC system at home, after hospital discharge. The research assistant asked participants to imagine they were now home and undertake the required daily patient-user test activities including using the vital signs equipment, responding to surveys on the tablet, and connecting with a nurse through a secure video visit. The eTrAC system was programmed to display simulated vital signs in demonstration mode. The portable vital signs monitors used by the participants did not display their actual vital signs.
Across all user testing sessions, the research assistant asked participants to
The research assistant used an observation rubric to evaluate participants’ performance of test activities, according to the following designations:
Participants were asked to rate their perceived satisfaction with the Guardian or eTrAC system user experience in the context of the workflow training we provided. To solicit this rating, we used the 11-point, single-item Net Promoter Scale (NPS) [
Immediately following each user testing session, the research assistant conducted a 60-min semistructured debrief interview with participants to further identify root causes of any observed difficulties during the simulation, discuss required tasks that may have been missed, and solicit the participants’ overall impressions of their experience using the systems [
Descriptive statistics were used to summarize participants’ demographic characteristics and user performance and acceptance of RAM systems and workflows. All qualitative data, including documented observations and audio recordings of the debrief interviews, were transcribed verbatim. Qualitative analysis was conducted employing inductive, thematic content analysis methods [
A total of 26 nurses from Canada (CAN group, n=15) and the United Kingdom (UK group, n=11) participated in the Guardian or eTrAC user testing. The majority of nurses were white females, possessing a bachelor’s degree in nursing, and employed full time. On average, these nurses had been practicing nursing for over 16 years, in cardiac and vascular surgery and other acute care settings as shown in
Nurse participant characteristics (n=26).
Nurse characteristics | Values | |
|
||
|
Male | 4 (15) |
|
Female | 22 (85) |
|
||
|
White | 21 (81) |
|
African decent | 4 (15) |
|
Asian | 1 (4) |
|
||
|
Professional degree | 6 (23) |
|
Bachelor’s degree | 11 (42) |
|
Masters’ degree | 7 (27) |
|
Diploma | 2 (8) |
|
||
|
Full-time | 19 (73) |
|
Part-time | 7 (28) |
Number of practicing years, mean (SD) | 16.5 (12) |
A total of 11 patients (CAN: n=6; UK: n=5), participated in the eTrAC user testing across both study sites. The majority of patients were male, either married or widowed, and retired. All patients were over 65 years of age; the majority had undergone coronary artery bypass graft or valve replacement surgery as shown in
Electronic Transition to Ambulatory Care patient participant characteristics (N=11).
Characteristics | Values, n (%) | |
|
||
|
Male | 7 (64) |
|
Female | 4 (36) |
|
||
|
White | 11 (100) |
|
||
|
Married | 7 (64) |
|
Widowed | 3 (27) |
|
Divorced or separated | 1 (9) |
|
||
|
Some high school—no diploma | 5 (46) |
|
High school diploma | 3 (27) |
|
Trade, technical, vocational training | 1 (9) |
|
Professional degree | 2 (18) |
|
||
|
Full-time | 2 (18) |
|
Part-time | 3 (27) |
|
Retired | 6 (55) |
|
||
|
Coronary artery bypass graft | 6 (55) |
|
Abdominal aortic aneurysm repair | 1 (9) |
|
Heart valve replacement | 4 (36) |
User performance, expressed as percentage of participants observed by task category, that is,
User performance.
User (N) and task | Completed, n (%) | Completed with difficulty or additional prompting, n (%) | Not completed, n (%) | Task completion time (mm:ss), median (IQR) | |
|
|||||
|
Nurse pairing the patient to the monitor | 11 (79) | 3 (21) | 0 (0) | 00:10 (00:05-00:11) |
|
Assign wireless devices to the patient | 9 (64) | 5 (36) | 0 (0) | 04:30 (03:10-06:16) |
|
Complete full set of vital signs | 14 (100) | 0 (0) | 0 (0) | 01:04 (00:40-01:47) |
|
Validate EWSc | 13 (93) | 0 (0) | 1 (7) | 00:03 (00:02-00:05) |
|
Review and manage the patient’s vital sign trends | 8 (58) | 6 (42) | 0 (0) | 00:26 (00:17-00:47) |
|
Wireless device management | 12 (87) | 2 (13) | 0 (0) | 02:08 (01:10-03:17) |
|
Infection control procedures | 14 (100) | 0 (0) | 0 (0) | 01:03 (00:30-01:50) |
|
|||||
|
Turn on device | 9 (82) | 1 (9) | 1 (9) | 00:08 (00:05-00:15) |
|
Take vital signs (BPe, SpO2f, weight, HRg, temperature) | 8 (73) | 3 (27) | 0 (0) | 01:01 (00:45-01:14) |
|
View scheduled appointment in the calendar | 11 (100) | 0 (0) | 0 (0) | 00:22 (00:18-00:43) |
|
Engage in follow-up surveys | 9 (82) | 2 (18) | 0 (0) | 00:16(00:12-00:20) |
|
Interface with nurse | 10 (91) | 1 (9) | 0 (0) | 00:16 (00:06-00:39) |
|
|||||
|
Log in and enroll new patient | 11 (92) | 1 (8) | 0 (0) | 00:41 (00:31-01:18) |
|
Assign H2Hh protocol | 6 (50) | 5 (42) | 1 (8) | 01:55 (01:14-02:21) |
|
Assign BTEi devices | 0 (0) | 11 (92) | 1 (8) | 03:35 (03:10-04:47) |
|
Review score and triage the patient | 5 (42) | 6 (50) | 1 (8) | 00:47 (00:28-01:07) |
|
Video call and patient wound photo | 12 (100) | 0 (0) | 0 (0) | 02:35 (01:57-03:49) |
|
Appropriate escalation of care | 12 (100) | 0 (0) | 0 (0) | Verbal response (not timed) |
|
Add clinical notes | 12 (100) | 0 (0) | 0 (0) | 01:12 (00:46-01:34) |
aCAN: Canada.
bUK: United Kingdom.
cEWS: early warning score.
deTrAC: electronic transition to ambulatory care.
eBP: blood pressure.
fSpO2: blood oxygen saturation.
gHR: heart rate.
hH2H: hospital-to-home.
iBTE: Bluetooth-enabled.
The majority of nurse participants were able to complete most required tasks independently, demonstrating comprehension and retention of required Guardian system workflows, for example, prompting the system to complete a set of
Nurse users demonstrated confidence with eTrAC workflows related to onboarding patients onto the system, as well as direct patient interaction and remote patient management, including assessment, documentation of independent nursing actions, and escalation of care to the most responsible physician in the patient case scenario. These users were less confident in working with system protocols for remote wireless patient vital signs transmission, such as assigning the Bluetooth-enabled vital signs devices to the patient for home use and assigning the appropriate hospital-to-home monitoring regimen based on surgical procedure.
The majority of patient users demonstrated ease and independence with all required eTrAC tasks. Similar to nurses, some required additional prompting to work with the Bluetooth devices to take their vital signs and navigate aspects of the system interface related to remote self-monitoring (eg, responding to symptom survey).
Individual and mean NPS ratings, by user group, are presented in
User satisfaction—Net Promoter Scale score.
User (N) and group | Raw scores (range 0-10) | Value, mean (SD) | NPSa score (% of promoter−% of detractors) | |
|
8.8 (0.89)d | 64 | ||
|
Nurse 1 | 8 |
|
|
|
Nurse 2 | 8 |
|
|
|
Nurse 3 | 8 |
|
|
|
Nurse 4 | 8 |
|
|
|
Nurse 5 | 7 |
|
|
|
Nurse 6 | 9 |
|
|
|
Nurse 7 | 10 |
|
|
|
Nurse 8 | 10 |
|
|
|
Nurse 9 | 10 |
|
|
|
Nurse 10 | 9 |
|
|
|
Nurse 11 | 9 |
|
|
|
Nurse 12 | 9 |
|
|
|
Nurse 13 | 9 |
|
|
|
Nurse 14 | 9 |
|
|
|
7.7 (1.4)d | 25 | ||
|
Nurse 1 | 4 |
|
|
|
Nurse 2 | 7 |
|
|
|
Nurse 3 | 8 |
|
|
|
Nurse 4 | 7 |
|
|
|
Nurse 5 | 8 |
|
|
|
Nurse 6 | 8 |
|
|
|
Nurse 7 | 8 |
|
|
|
Nurse 8 | 8 |
|
|
|
Nurse 9 | 9 |
|
|
|
Nurse 10 | 9 |
|
|
|
Nurse 11 | 9 |
|
|
|
Nurse 12 | 9 |
|
|
|
9.2 (0.75) | 82 | ||
|
Patient 1 | 8 |
|
|
|
Patient 2 | 8 |
|
|
|
Patient 3 | 9 |
|
|
|
Patient 4 | 10 |
|
|
|
Patient 5 | 10 |
|
|
|
Patient 6 | 10 |
|
|
|
Patient 7 | 9 |
|
|
|
Patient 8 | 9 |
|
|
|
Patient 9 | 9 |
|
|
|
Patient 10 | 9 |
|
|
|
Patient 11 | 10 |
|
|
aNPS: Net Promoter Scale.
bCAN: Canada.
cUK: United Kingdom.
dThis is the average score.
eeTrAC: electronic transition to ambulatory care.
Posttest debrief interviews provided opportunities for users to reflect on their own performance and how they felt during the test simulations, any areas of difficulty that they had, and what (if any) improvements to system workflow training could be made. The participant’s overall accounts of their user experience—positive or negative—were also solicited.
Key themes that emerged from the interviews of nurses engaged in the Guardian user testing related to system
In terms of
It does the job...more frequently than a nurse can. We are only one nurse taking care of 4 to 5 patients, so if our monitor can do continuous monitoring and alert us when our patient is [deteriorating], that’s unbelievable.
Some nurses cited unfamiliarity with more advanced aspects of the system as a barrier to engaging in vital signs
I thought that was the coolest thing. You can monitor your patient from [your handled device], the desktop central station, or from the monitor, at the bedside. So you don’t have to be at the bedside all the time to know [patient status].
Reflections on
I think it’s going to be really safe. If I can constantly know that they’re [patients] going to be okay if I leave them and do other things and it’s just very quick and easy.
I think it’s awesome that it is barcodes and scanning and no data entry. I think half our shifts are wasted with data entry—we don’t need any more of that!
Nurse participants who were debriefed following the eTrAC user testing reflected on this system as an enabler of their
It’s quite cool to see all your patients and the alerts. Because, you know, you could have twenty patients on there, and they’re all fine, making a good recovery. I like the way the alerts and the scores are visible and you can act on it straight away.
Most participants commented that they needed additional prompting to assign hospital-to-home protocols and to assign the Bluetooth-enabled vital signs devices to the patient and tablet. Lack of familiarity and confidence with the technical aspects of the eTrAC interface were discussed as key challenges to completing these tasks. When asked, all participants said they would need and would welcome the opportunity to develop these technical skills further, and that with additional support, they could see themselves becoming proficient in these aspects of eTrAC use.
Patient debrief interviews revealed an overall positive experience with the eTrAC user testing, with
At first I thought I couldn’t do it but again, like I said, it is very straightforward. Very easy, you start at the top and just finish the temperature or the height, or your weight, and you just follow the tablet.
All participants remarked that they felt the system would be invaluable for helping them through recovery. There was a high degree of enthusiasm about connecting with a nurse daily and being monitored, as it would offer a sense of security after hospital discharge:
I think that’s the best thing of all... there’s somebody at the end of that—just like telephone line, there’s somebody at the end of that you can talk to and you can see them... that’s really good.
Participants also commented on the value of engaging in eTrAC patient surveys to give a monitoring nurse more information and ensure that they are on track with recovery:
I would give it [survey feature] a 10 plus, plus. I think it is just comforting to know that you are on the right track and can tell the nurse what’s happening.
In summary, participant debrief interviews indicated a high degree of acceptance among users. Nurses expressed the importance and potential of remote monitoring and virtual hospital-to-home care as means to improve efficiency of clinical workflows, enhance patient safety, and facilitate timely clinical action. Patient users spoke to the security that these systems can offer through daily connection with a nurse while recovering from surgery. Both user groups stressed the need for additional opportunities to practice in order to become comfortable and proficient in the use of the Guardian and eTrAC systems, with respect, in particular, to mastering more technical aspects related to enabling remote connectivity and assigning and engaging in monitoring protocols.
This study addressed user performance and acceptance of Philips’ Guardian and eTrAC systems designed to support in-hospital RAM and virtual care from hospital-to-home, respectively [
These user performance results were used to enhance our approach to systems training during SMArTVIEW trial start up at participating hospital sites. Initial systems in-services for nursing staff were followed by individual facilitated practice sessions both in classroom settings and on the surgical wards. These applied learning opportunities allowed for the development of ward nurses’ required technical skills to become proficient in the use of Guardian, while they transitioned from case-based learning to live systems use. Some nurse participants also became designated Guardian
Given that the use of the Philips eTrAC hospital-to-home system [
This study demonstrated a high degree of acceptance in terms of user satisfaction and communication of a positive learning experience, highlighting the value of providing risk-free opportunities to learn RAM and virtual care technologies, before implementation, to ease end-user apprehensions and achieve buy-in. A few other studies have examined specifically user experience in the context of RAM and virtual care technology planning or pilot testing in surgical settings. In their recent multimethod study to examine nurse and physician perceptions of a planned introduction of continuous RAM on general hospital wards, Prgomet et al [
As was the case in our study, however, the opportunity to trial the monitoring devices and engage in dialogue about their impact on clinical workflows and patient care gave rise to perceptions that focused training, featuring educational opportunities to address pre-existing attitudes and beliefs about the incorporation of RAM technologies into clinical practice, would be an important prerequisite to successful implementation [
In a prospective study (N=443), McElroy et al [
The VItal siGns monitoring with continuous puLse oximetry And wireless cliNiCal notification aftEr surgery study investigators [
Potential limitations of this study include our homogenous participant sample, as well as our approach to measuring task completion times and level of interaction with participants during the
As is common during formative types of user tests that are intended to reveal shortcomings in systems training or workflows [
We also undertook a flexible approach to participant moderation during the
The inadequacy of current systems for postsurgical patient monitoring in hospital and at home is a major factor contributing to postoperative complications, death, and unplanned hospital readmissions [
eCare Coordinator
electronic transition to ambulatory care
Net Promoter Scale
remote automated monitoring
randomized controlled trial
blood oxygen saturation
TecHnology-Enabled remote monitoring and Self-MAnagemenT—VIsion for patient EmpoWerment following Cardiac and major VasculaR surgery
This study was funded by the Canadian Institutes of Health Research (grant no. 348440), the Ministry of Health, and the Hamilton Health Sciences Strategic Research Initiative. In-kind industry support was provided by Philips. MM holds the Heart and Stroke Foundation/Michael G DeGroote Endowed Chair in Cardiovascular Nursing.
MM is the principal investigator of this study and has contributed toward conceptualization, study design, protocol writing, user testing, data analysis, and manuscript writing. CO has contributed toward user testing, data collection, data analysis, and manuscript writing. AG has contributed toward study coordination, user testing, and data management. MB has contributed toward data analysis and manuscript writing. SH has contributed toward user testing and data collection. WC has contributed toward user testing, data collection, and manuscript review. AT has contributed toward user testing, data collection, and manuscript review. PR has contributed toward study design and protocol writing. SR has contributed toward study design and protocol writing. ND has contributed toward protocol writing and user test cardiac patient case writing. AL is the Canadian site principal investigator and has contributed toward user test case review and approval. RW has contributed to development of participant recruitment process. CL has contributed toward installation and management of the RAM system and technical study setup. JW has contributed toward installation and management of the RAM system and technical study setup. KP has contributed to installation and management of the RAM system and technical study setup. JD has contributed to the development of the posttest interview guide. KS has contributed to data analysis and manuscript writing. FE has contributed to protocol writing and user test vascular patient case writing. TS has contributed to study conceptualization and hospital technical services procurement. JM is the UK site principal investigator and has contributed toward user test case review and approval. DH has contributed to user test cardiac patient case writing in the United Kingdom. MF has contributed toward user test vascular patient case writing in the United Kingdom. PH has contributed toward data analysis and manuscript writing. SY has contributed toward data analysis and manuscript writing. EP has contributed to development of qualitative analysis methods within the protocol. SB has contributed toward study conceptualization and principal investigator and team training in out-of-the-box usability testing methods. PD is the coprincipal investigator of this study and has contributed toward conceptualization, study design, protocol writing, user testing, data analysis, and manuscript writing.
MM and PD are members of a research group that does not accept honorariums or other payments from industry for personal financial gain. They do accept honorariums or payments from industry to support research endeavors and costs to participate in meetings. On the basis of study questions PD has originated and grants he has written, he has received grants from Abbott Diagnostics, Boehringer Ingelheim, Covidien, Octapharma, Philips Healthcare, Roche Diagnostics, and Stryker. PD has participated in a consultancy advisory board meeting for Boehringer Ingelheim.