Co-Creation and Usability Testing of a Digital Cardiac Rehabilitation Program (eCardiacRehab): Design and Development...

Cardiac rehabilitation (CR) is a class IA-recommended treatment and secondary preventive strategy for people with coronary artery disease. eHealth solutions show promise in providing accessible CR. However, few provide a comprehensive and multimodal CR program, and most programs are developed without input from end users.

The aim of this study was to provide a detailed description of the multidisciplinary co-creation process used to develop a person-centered, multimodal digital CR program that integrated the perspectives of stakeholders and end users throughout, with the rationale to optimize the acceptance and feasibility of the CR program.

We incorporated a user-centered design with a 3-phase, iterative, multidisciplinary stakeholder co-creation process. This included defining needs (phase 1), development and refinement (phase 2), and testing and optimization (phase 3). Overall, 26 internal stakeholders from the project team participated, including clinicians, researchers, software developers, and user representatives. In addition, 35 external stakeholders (20 clinicians and 15 people with cardiac-related problems) participated in a user-centered development process that included workshops, intervention content development, and usability testing. Data were collected through contextual inquiry, 4 workshops with stakeholders, 12 co-creation sessions with user representatives, 2 usability testing sessions using a think-aloud methodology, standardized usability surveys, and individual and focus group interviews. Intervention content was developed and finalized based on existing evidence, stakeholder input, and user testing. A smoke test and a minimum viable product test were conducted. Data were analyzed using rapid qualitative content analysis and descriptive statistics.

Analyses of data gathered across the 3 phases identified 5 themes important to stakeholders and end users: a program with (1) personalized and tailored solutions with reliable, trustworthy, and evidence-based content (ie, a face-to-face introduction session at the start of the program and a tailored registration page to individually register personal risk factors, goals, and medications); (2) options for feedback (ie, an asynchronous messaging service and tailored face-to-face video consultations with clinicians); (3) peer support (ie, exercise sessions in groups); (4) digital reminders (ie, notifications on a smartphone or tablet); and (5) motivational features (ie, interactive cardiac-specific learning modules on coronary artery disease and secondary prevention). Evidence-based content development resulted in 9 cardiac-specific interactive learning modules, a module for personal health data entry, live exercise sessions, tailored digital follow-up, and an asynchronous messaging service. Readability was assessed using the Gunning Fog Index, with levels ranging from 4 to 13. The overall System Usability Scale score was 86.2 (SD 12.2), indicating excellent usability.

A multidisciplinary stakeholder co-creation process combining well-known evidence-based concepts with stakeholder input identified several areas for improvement and facilitated the development of the digital CR program. Contextually tailored, co-designed interventions may improve relevance and responsiveness to user needs. The feasibility and effectiveness of the program will be further evaluated in the eCardiacRehab trial.