This was a qualitative secondary analysis of individual interviews and focus group data from a larger primary study that developed an electronic care transition tool to improve health outcomes of patients with MCCs using a stakeholder-centered design approach [14].

The original primary study was conducted at Brigham and Women’s Hospital, a major academic medical center in New England, in the Northeastern United States. Health care providers and staff including hospitalists, outpatient physicians, physician assistants, nurse practitioners, nurses, and case managers were eligible to participate, as were patient advisors from the Brigham and Women's Hospital patient and family advisory council who were patients with MCCs who had been previously hospitalized. Purposive [16] recruitment occurred through email, including a detailed study purpose description. Health care providers and staff completed individual interviews, while patient advisors were randomly assigned to 1 of 3 focus groups for the ease, comfort, and schedules of the participants and to support open stakeholder communication with the study team.

For the primary study, the study team used a stakeholder-centered [17] design approach as the underlying conceptual basis for the planned research. The study team conducted both individual, virtual interviews involving multidisciplinary care providers and clinical staff, along with virtual focus groups involving patient advisors. Interviews and focus groups, conducted by multiple experienced team members and not exceeding 1 hour in length, continued until saturation [18] was reached. As part of the data collection in the primary study [14], participants openly shared and expounded on their views of educational content necessary for an effective electronic care transition tool. A secondary qualitative analysis was conducted to explore specific educational content research questions, yielding insights beyond the original scope of the primary study and addressing issues identified as important to the participants [19,20]. This report details this secondary qualitative analysis and the results. The methods used to collect the data used in the primary study have been published previously, as were the participant demographics [14]. Therefore, the purpose of this secondary analysis was to identify and explore the educational requirements of patients with MCCs for the e-clinical pathway as expressed by the participants in the primary study.

Interview guides, developed based on a literature review and reviewed by experts, were used for the focus groups and interviews, which were conducted with 12 health care providers and staff and 11 patient advisors in the primary study. The resulting transcripts, transcribed verbatim and anonymized, were the data corpus for this secondary qualitative analysis. Codes were generated both deductively from the interview guide and research questions using a template and framework matrix [21] and inductively from the primary study data, resulting in an inductive and deductive hybrid thematic analysis [22-24]. Three authors (CT, HW, and JRJ) performed the coding and deliberated the results. The remaining authors reviewed the analysis; discrepancies were discussed and resolved through team consensus. The analysis was iterative [25,26] and included team members to contribute to study reliability [27]. Throughout the process, regular team meetings and communications were conducted to calibrate data collection, to discuss findings, and to examine patterns and potential conclusions, encouraging team reflexivity [28,29]. The qualitative results were thereafter used to build an educational requirements Microsoft Excel spreadsheet, which was vetted by clinical experts and iteratively refined.

The Mass General Brigham Institutional Review Board (IRB) reviewed and approved all study activities (protocol 2022P001475) in addition to the University of Massachusetts Boston IRB (IRB ID 3476). Informed consent, including participants' ability to opt out, was received from all study participants before study participation. Resulting data were anonymized and deidentified, and strict confidence was maintained. All participants received a US $50 gift card at the end of study participation.

A total of 23 individuals (n=12 clinical staff or primary care providers and n=11 patient advisors) participated in the original study; the majority were female (n=18) and White (n=19). The clinical staff or health care providers did not provide their ages; however, the ages of 10 of the 11 patient advisors ranged from 60 to 79 years. Participants in the original study described preferred education content, education considerations, and education presentation and display, and we identified through the qualitative secondary analysis the following themes regarding specific education requirements for MCC transitions: (1) essential end-user education includes condition-specific, nutrition-specific, and medication-related content; (2) education must be accurate, accessible, and consider end-user health literacy; and (3) education presentation can be enhanced with graphics, reminders, and end-user resources. The findings further resulted in a completed education pathway (Multimedia Appendix 1), with targeted and specific content for MCC transitions.

As detailed in Table 1, the participant preferences expressed through the themes resulted in several implications for the sources of education content and the education pathway. The education content included medical condition–specific content for all 3 included conditions, with nutrition and medication content tailored to each condition. The primary education source was MedlinePlus, along with other reputable health websites, and all education links were structured and organized for end-user accessibility and health literacy.

The presentation of education included visual aids and graphics to enhance education; reminders to alert end users to available education content; and resources including a digital health navigator for end-user support (Table 1). These resulting implications were all directly addressed as the team developed and refined the education content pathway (“education pathway;” Multimedia Appendix 1).

The 3 conditions (and combinations of MCCs including DM, CHF, and CKD) were mapped onto an education pathway organized by postdischarge day and then curated, prioritized, and linked. Education will be pushed to the participant’s app interface, depending on the participant’s condition and postdischarge day, following the pathway. A section of the education pathway is excerpted in Table 2; the full spreadsheet of the final resulting education pathway is included in Multimedia Appendix 1, with live hyperlinks for freely available education content.

While MedlinePlus [30] education sources make up most of the knowledge links, additional information was added to supplement CKD education, including information from the American Kidney Fund and the National Institute of Diabetes and Digestive and Kidney Diseases, which are also open source. As indicated in Table 2, several education content topics were included within each week, and this is further depicted in Figure 3. The article title is displayed as the display text, and these titles are hyperlinks directly linked to web pages (and live). Noted with more detail in the full education pathway in Multimedia Appendix 1 are the additional scripts that help orient the patient or user to the learning objective anticipated if the article link is clicked and read.

Through the secondary qualitative analysis of the data corpus, we identified necessary educational requirements of postdischarge information for patients with MCC, along with critical aspects of online patient education and, thereafter, transformed the findings into a targeted education content pathway. In sum, we have developed MCC care transition educational content that was integrated into our e-clinical pathway and application, also described in additional detail in a previous publication [14].

Barriers to self-efficacy for patients with chronic disease, including health literacy, access, and support, can be addressed with mobile apps and self-management programs [31,32]. Existing literature confirms the focus of this study and its findings, including the potential for apps to support self-management [33]. One randomized controlled trial of a personal health record mobile app found a maintained vs declining quality of care among participants who experienced the intervention [34]. Other literature has detailed how participants felt supported in their goal tracking through a mobile app [35] and reported increased motivation for behavior change [36]. As such, digital health technologies do have the potential to support patient outcomes. However, digital health technologies with targeted information for the education of patients with MCCs are key. Targeting self-management in the transition from hospital to home is critical in the education of patients with MCC. Despite the need, many educational resources, including online applications, only target one chronic illness, such as heart failure [37], or a specific self-management concept, such as fluid tracking [38]. Here, the team focused on providing comprehensive MCC educational content without contributing to cognitive overload. MedlinePlus [30] is the primary education source for the app education pathway and is a validated and free source of consumer health care educational content. In contrast to the available education from MedlinePlus for DM and CHF, unfortunately, detailed CKD information was insufficient for the established educational requirements. This is further illustrative of similar challenges with education scholarship for patients with CKD. For example, 1 review of available CKD apps found that nephrologists’ app evaluations indicated the health care providers perceived a lack in quality in the available content [39]. Another study evaluating CKD websites found that their evaluation justified the recommendation for content improvements [40]. Furthermore, existing literature also reflects the continued challenges with inadequate app use rates and insufficient engagement with digital health interventions [41,42], reflecting an ongoing tension with the app intentions and their ultimate success. We further note that although this study focused on the isolated component of education (within a larger MCC app with a core innovation of integration across the care continuum), the bidirectional data exchange between the app and the electronic health record system has the potential to enhance shared decision making [43] and information exchange, including among patients, caregivers, and health care providers. This potential remains a future area of interest and scholarship.

Additionally, the educational pathway is generalizable and reproducible in other health care systems. It is also potentially useful outside of health care institutions as a structure establishing an end-user guided process on a mobile app. The work and process of the study team and the resulting education pathway are detailed and included in this manuscript specifically so that other health care systems, or others, can freely replicate the process. This information provided could be used by another facility to adjust the e-clinical pathway for their own needs, based on the description of the process in this manuscript and other related manuscripts [14], minimizing process burden and cost. The team used content in the public domain, which is generalizable as this content can be easily adopted and used in low resource settings. Stakeholder involvement in the educational requirement process was intended to increase potential uptake and dissemination [44]; disseminating knowledge increases the potential for impact [45]. Although other educational sources were considered, often with many benefits, including curated and organized content, one critical aim was to make the education pathway a process that could be replicated. As such, the study team decided to primarily use MedlinePlus [30] for the educational content, along with open-source CKD education from the American Kidney Fund and the National Institute of Diabetes and Digestive and Kidney Diseases. While MedlinePlus [30] is an exceptional, well-sourced, federally backed, and free education source, there were aspects of this education source that were oftentimes unwieldy, expansive, and not limited to care transitions information. Future work should consider positioning analysis within a framework of integrated care [46] or collaborative care models [47] to emphasize system-level requirements for cross-sector information flow and accountability.

Finally, the importance of accessible language, digital health navigators, and family involvement evident in the results also indicates concordance with the existing literature. Adult health literacy proficiency remains low and mobile apps focused on language and end-user accessibility can support aspects of health literacy, including health information seeking [48]. Participants in this study expressed their desire for robust support, such as through a digital navigator, and this is reflected in the available science expounding on the potential positive impact of digital health navigators on patient app use [49]. Participants also brought up the positive impact of family involvement in their own digital health technology experiences; existing scholarship confirms that family engagement and support can facilitate patients’ adoption of a digital health solution [50], although further studies should also consider the digital literacy of caregivers as a complementary identified need [51]. In sum, future work involving mobile apps and other digital health technologies should remain mindful of the many barriers to participant recruitment and technology use, although our results suggest patient and family engagement, digital health navigator involvement, and language accessibility may be modifiable and successful factors to consider.

This work has some limitations that should be noted. First, this study was conducted among participants very engaged with health care services and knowledgeable about the postdischarge process. However, this study intentionally and purposefully included early stakeholder involvement, extensive health care provider and patient representative reviews and feedback, and iterative work with the study team and experts to succinctly create targeted and essential educational content. Second, the secondary qualitative analysis of educational requirements was conducted before app completion and testing. Future work will be needed to confirm and validate educational content fit with app end-user needs and larger primary study aims. Future work will also need to consider sustainability of the app overall, including maintenance of education content and user feedback. Third, the secondary qualitative analysis methodology of the original dataset inherently constrains a full understanding of e-care team coordination and interprofessional perspectives. Future scholarship directly addressing these critical perspectives is needed.

This study effectively produced, organized, and vetted the educational requirements to support a patient with MCCs during the critical posthospitalization transition period. Our secondary qualitative analysis extended the work of the primary study with a conceptual focus on patient and caregiver educational requirements. Study findings support a deeper understanding of end-user education requirements and further enhanced the resulting education resources intended for the app in the primary study. The end-user educational requirements and the included resulting education pathway implemented in the study app are freely available to support future research, implementation, and evaluation efforts (including, potentially, contextual tailoring, scalability, and impact testing) aimed at improving care transitions for individuals with MCCs.