An Internet-Based Intervention for Cardiovascular Disease Management Integrated With Primary Care Electronic Health Records: Mixed Methods Evaluation of Implementation Fidelity and User Engagement

Genevieve Coorey, David Peiris, Anish Scaria, John Mulley, Lis Neubeck, Nashid Hafiz, Julie Redfern

Research output: Other contributionDiscipline Preprint RepositoryResearch



Evidence is growing for the benefits of eHealth interventions to support increased patient engagement and outcomes for a range of health conditions. However, ineffective program delivery and usage attrition limit exposure, and may impact effectiveness.


To evaluate delivery fidelity of a consumer-focused eHealth intervention, describe usage patterns, compare clinical outcomes between low and high users, and identify mediating factors on delivery and receipt of the intervention.


Mixed-methods study of an internet-based intervention being evaluated in a randomised trial. The intervention comprised: (1) medication and cardiovascular disease (CVD) risk data uploaded from the primary care electronic health record (EHR); (2) interactive personalised CVD risk score estimation; (3) goal setting and self-monitoring/tracking; (4) an interactive social forum; and (5) optional text message and/or email receipt of heart health actions. Fidelity was assessed over 12 months. Trial outcomes were compared between low and high intervention users. Data sources included program delivery records, web log data, participant trial data, and thematic analysis of staff-participant communication records.


Most participants allocated to the intervention group (451/486, 93%) had initial interaction with the intervention via a training session, conducted by telephone (92% of participants trained) with a mean duration of 44 minutes (range 10-90 minutes). Staff conducted 98% of the expected follow-up contact (1776/1804 expected episodes), mostly by telephone or email (80% of episodes). Of those who commenced logins (n=451), 47% were low users (defined as at least one login in three or fewer months of follow-up); 40% were high users (defined as at least one login in more than three months of follow-up); 13% were non-adopters (defined as no logins after the initial training session). Mean login frequency was three to four per month in ongoing users. There was no significant difference between the groups for the primary trial outcome of adherence to guideline recommended medications (P=.44). There was significant difference for dietary fish serves per week (P=.0005) and metabolic equivalents (METs) scores (P=.042). Usage intensity of interactive features was highest for personalised goal tracking and lowest for the social media/chat forum. Features with EHR-derived data held only early interest for most users. Four fidelity measures (reach, content, dose delivered, and exposure) were influenced by three key factors: facilitation strategies used by staff; ‘invisible’ qualities of staff-participant communication; and participants’ responsiveness to intervention features.


A multi-feature internet-based intervention with EHR-linkage was delivered with high fidelity to the trial protocol. The intervention was regularly used by 40% of users over 12 months. Higher login frequency as an indicator of greater intervention exposure was associated with improvement of some lifestyle-related outcomes but not eHealth literacy score or clinical outcomes. Attributes of the intervention and individualised participant support influenced initial and ongoing use. Clinical Trial: N/A
Original languageEnglish
PublisherJMIR Preprints
Publication statusSubmitted - 29 Oct 2020
Externally publishedYes


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