The present qualitative study was conducted as part of the Mobile Technology Enabled Rehabilitation-Acute Coronary Syndrome (MoTER-ACS) project. The overall aim of this project was to provide smartphone-based postdischarge educational and health interventions for patients with ACS. There were several reasons why focus group interviews were chosen as the method of data collection. First, this allowed us to identify a wide range of feelings, beliefs, and perspectives on the topic. Second, a group interview generates interaction and makes participants think about specific examples of strategies that would remain uncovered when using other methods of data collection, such as questionnaires or individual interviews. This interaction also makes it much easier to avoid suggestive or leading questions that hint at a specific strategy.

We conducted a focus group with health care professionals to explore their unique viewpoints. All participants were recruited from the Department of Cardiology at the Prince Charles Hospital (TPCH), Queensland, Australia. The focus group (n=10) consisted of a multidisciplinary team of cardiovascular experts, including 2 nurse practitioners, 3 cardiologists, 2 research scientists, 2 clinical nurses, and 1 physiotherapist.

Participants were asked to provide written consent to the audiotaping of the session and completed a short questionnaire on demographics information and their professional roles in the Department of Cardiology. Subsequently, the topic of the focus group was introduced, and to facilitate an open discussion, it was emphasized that participants were free to express their opinions, with both positive and negative responses being respected. In order to help the health care professionals become familiar with the specifications of the MoTER-ACS application and its Web portal, we presented a short video clip and a PowerPoint presentation of the features of a previously developed application and its portal for cardiac rehabilitation [15]. The smartphone app and its Web portal were used for the demonstration of graphs, content, and exercises.

In order to obtain standardization and consistency, a semistructured questioning guide had been developed by the researcher, which started with an icebreaker question asking participants about their experiences of using information communications technology-based interventions during their professional practice. The questioning guide included topics relevant to the contents and strategies that health care providers are interested in when considering a smartphone-based app, and the possible barriers to the engagement of patients with the intervention. Examples of topics and related questions are presented in Table 1. The study procedure was approved by the TPCH Human Research Ethic Committee.

Two different methods were used for the analysis of focus group data. Figure 1 shows an overview of the study data analysis methods. The first method was an inductive content analysis that resulted in themes emerging from the data [16]. Verbatim transcriptions of the audiotaped session were generated, which then researcher read to familiarize herself with the data. The focus group transcriptions were imported into NVivo 11.0 for thematic analysis [17]. The NVivo software helps researchers to manage and organize data, facilitating the process of analysis, the identification of themes, the collection of insight, and the drawing of conclusions [18].

Thematic analysis allows the identification of themes from different levels within the data. An important part of this qualitative method of analysis was to devise a coding framework that helped to structure and reveal themes within the text [19]. We assigned codes to the text fragments, reflecting the words spoken by the participants in a more abstract way. Finally, the number of codes was reduced by combining similar codes into more comprehensive themes [16], and the expectations per questions resulted in a recommendation to include (clear majority of positive expectations) or exclude (clear majority of negative expectations) each theme in a smartphone-based intervention. NVivo requires the researcher to code the data and develop themes or categories; therefore, one can argue that the data analysis is principally subjective and allows the researcher to engage more meaningfully in the process of analysis. In order to reduce bias toward the identification of subjective themes, we investigated the impact of medical domain concepts on the analysis of the focus group data in our second approach. We employed semantic technologies, more concretely domain ontologies, which contain domain “concepts,” their definitions, and their semantic relationships to each other, to extract the medical or clinical concepts from the focus group transcriptions.

Due to their narrative nature, the transcriptions of the focus groups usually exhibit noisy and inconsistent characteristics in terms of the terminologies used throughout the discussion (eg, “heart attack” disorder may be referred to as “cardiac infarction,” “myocardial infarction,” or simply “MI” by different participants in the focus group). The main advantage of considering concepts in such analyses compared with a word-level analysis is that by normalizing the transcriptions to their concepts, semantically similar terms and phrases are consolidated and a large portion of unrelated terms are removed. Hence, this concept-level representation of the transcripts can provide a solid platform for more effective pinpointing of the essential themes. Our concept-level analysis was performed through the following steps: (1) selecting the appropriate ontology, (2) annotating the transcripts using the selected ontologies, and (3) analyzing the extracted concepts and mapping or deriving codes or themes from them. The details of these steps are described below.

In total, 10 health care providers from the Department of Cardiology took part in this study. Among these, 70% (7/10) had experience in using mHealth interventions in their clinic or ward. Participants’ characteristics are depicted in Table 3, demonstrating the diversity of health care providers with a range of disciplines and backgrounds. The study results are presented as major themes in Table 4. We presented recommendations for a mobile phone–based app and its Web portal to provide health interventions to patients with ACS.

The first topic that participants recommended for consideration with respect to patients with ACS was educational materials, including instructions on diet, providing daily meal plans, and education on ACS symptoms and its concepts, considering the patient’s condition. Participants recommended to use the Heart Foundation website and the “My heart, my life” book as resources for patient education [25].

Four items were identified by the health care providers to be measured via the smartphone-based app, including body weight, blood pressure, mood, and pain. The use of the tool “European Quality of life Questionnaire-five dimensions” [26] was recommended to assess patients’ health status. Health care providers recommended assessing the pain level of patients with ACS using a scale of 0-10.

Two ACS symptoms, shortness of breath and chest pain, were identified as items that health care professionals provided a negative opinion regarding daily monitoring via the smartphone app. Furthermore, participants indicated that assessing patients’ electrocardiographs is not useful.

Another strategy mentioned by the focus group participants was providing a communication facility for health care providers with which to communicate with patients when required. Video conferencing applications (eg, FaceTime) were identified as useful tools that facilitate communication between health care providers and patients. Nonverbal communication and observation of patients’ body language through videoconferencing were also identified as useful assessment tools.

Older age, low educational level, and lack of access to technology were identified as patient barriers to engage with smartphone-based interventions. Participants also mentioned that staff workload may increase due to monitoring and providing online support and this would be considered as a potential barrier from health care providers’ perspective.

Health care providers pointed out using a monitoring mechanism or alarm system within the portal to inform clinicians of patients’ daily health measures and intervention usage.

Participants acknowledged the importance of long-term follow-up versus short-term to achieve sustainability of the smartphone-based intervention for postdischarge patients.

In this qualitative study, we investigated the expectations of health care professionals with respect to a smartphone-based app and its portal to empower patients with ACS. The focus group resulted in useful feedback regarding different contents and features of such an application to provide postdischarge support and health management for patients with ACS. The important themes that emerged were educational instructions, health measures (body weight, blood pressure, mood, and pain), not recommended for self-monitoring (chest pain, shortness of breath), real-time communication, engagement and motivational barriers, monitoring or alarm mechanism, and intervention follow-up.

Health care professionals were most positive about providing educational instructions related to diet and ACS symptoms. Providing patients with daily meal plans and information related to healthy eating were strongly recommended by the participants. This is consistent with the current evidence showing that healthy eating is associated with a lower mortality risk in a large cohort of cardiac patients [27].

The most negative feedback received from the health care professionals was about the daily monitoring of ACS signs and symptoms, including chest pain and shortness of breath, via the mobile phone app. Participants pointed out that these health measures are subjective and vague and that it is required for patients to adequately understand symptoms associated with their condition and recognize the possible underlying reasons.

The health care providers suggested that measuring patient health status, including emotions and pain, would be informative in providing sustainable postdischarge support for patients with ACS. It is evidenced that depression is common after a coronary event [28], and it continues to remain underrecognized and poorly treated in the cardiac population [29]. Previous research has shown that patients with ACS benefit from cognitive behavioral therapy following an episode of myocardial infarction [30]; therefore, measuring emotional status will assist clinicians to identify depressive symptoms.

Based on our focus group results, a visual communication tool is required to assess patient health status and to provide psychosocial support and encouragement during the intervention. Studies in the fields of chronic disease and rheumatology have also found that patients considerably value face-to-face supervision by a health care professional [31,32]. Furthermore, it is known that multiple communications with clinicians result in a lower dropout rate and better adherence to interventions [33]. Accordingly, this will increase patient motivation and engagement and improve their empowerment.

Being older, having a low educational level, and lacking computer skills were identified as engagement and motivational barriers. This is consistent with the current evidence describing potential barriers for mHealth interventions. While mHealth technologies have the potential to improve population health outcomes and the delivery of health care services, there is a need to use and develop mHealth applications with caution. Using smartphone-based SMS text messaging requires a certain level of literacy. In addition, researching the use of “apps” to provide education and patient engagement in elderly populations may be hindered by the prevalence or access of certain technologies, such as smartphones, within this population. While the mobile platform remains flexible to engage patients via written, verbal, or video interactions, there is a need to consider how the elderly or individuals without advanced technical skills will interact with the device or participate in the intervention [34].

The strengths of the study design include providing structured questions during the focus group, as well as screenshots of the smartphone app. Furthermore, the themes that emerged from the thematic analysis were validated using concept mapping methodology. Facilitators were successful in creating a comfortable conversation environment, and participants felt confident in raising their positive and negative opinions on smartphone interventions for the postdischarge management of patients with ACS. A few limitations should be considered. Due to time restrictions, we did not ask participants to discuss application usability or appearance; hence, this will be investigated in a future study with patient participants. Although clinicians are one of the key stakeholders in the use of mHealth technologies, the development of such interventions requires an iterative process of obtaining information and guidance from all stakeholders, including patients, information technology specialists, and providers. In this study, we aimed to focus on clinician perspectives, and patient perspectives will be investigated in a future study using different methodologies.