Electronic Support Tool Research Articles

Implementation of ED I-PASS as a Standardized Handoff Tool in the Pediatric Emergency Department.

Communication, failures during patient handoffs are a significant cause of medical error. There is a paucity of data on standardized handoff tools for intershift transitions of care in pediatric emergency medicine (PEM). The purpose of this quality improvement (QI) initiative was to improve handoffs between PEM attending physicians (i.e., supervising physicians ultimately responsible for patient care) through the implementation of a modified I-PASS tool (ED I-PASS). Our aims were to: (1) increase the proportion of physicians using ED I-PASS by two-thirds and (2) decrease the proportion reporting information loss during shift change by one-third, over a 6-month period. After literature and stakeholder review, Expected Disposition, Illness Severity, Patient Summary, Action List, Situational Awareness, Synthesis by Receiver (ED I-PASS) was implemented using iterative Plan-Do-Study-Act cycles, incorporating: trained "super-users"; print and electronic cognitive support tools; direct observation; and general and targeted feedback. Implementation occurred from September to April of 2021, during the height of the COVID-19 pandemic, when patient volumes were significantly lower than prepandemic levels. Data from observed handoffs were collected for process outcomes. Surveys regarding handoff practices were distributed before and after ED I-PASS implementation. 82.8% of participants completed follow-up surveys, and 69.6% of PEM physicians were observed performing a handoff. Use of ED I-PASS increased from 7.1% to 87.5% ( p < .001) and the reported perceived loss of important patient information during transitions of care decreased 50%, from 75.0% to 37.5% ( p = .02). Most (76.0%) participants reported satisfaction with ED I-PASS, despite half citing a perceived increase in handoff length. 54.2% reported a concurrent increase in written handoff documentation during the intervention. ED I-PASS can be successfully implemented among attending physicians in the pediatric emergency department setting. Its use resulted in significant decreases in reported perceived loss of patient information during intershift handoffs.

Extended Pharmacist Assessment of Medication Safety for Nursing Home Residents-A Cross-Sectional and Prospective Study.

In the routine pharmacist's medication review in ambulatory care and nursing homes in Germany, clinical diagnoses are often insufficiently considered as they are frequently not accessible to pharmacists and their electronic support tools. This may leave a significant proportion of medication-related problems (MRP) undetected and unresolved. Moreover, limited and incomplete data may promote spurious alerts of low clinical relevance. In order to assess the impact of improved data availability, we conducted a study (German Clinical Trials Register DRKS00025346) to evaluate the impact of an extended pharmacist's medication review, made possible by diagnosis data being routinely available to the pharmacist. At six nursing homes in the Nuremberg metropolitan area, 338 patients treated by 32 physicians were enrolled. A pharmacist's medication review, considering only the medication data, identified 114 potential MRPs, and additional consideration of diagnoses further identified 69 potential MRPs. The physicians adapted the therapy in response to 69.9% of alerts. The observed gain in MRP identified indicates that efforts should be intensified to facilitate and improve consideration of drug-diagnosis-related MRP by improving data sharing and communication between pharmacists and physicians caring for nursing home residents.

Pilot testing of a new electronic diagnostic support tool (AiD-DST) designed to identify the cause(s) of delirium

Introduction Delirium is frequently multifactorial, and causes are often missed in clinical practice. The Aetiology in Delirium - Diagnostic Support Tool (AiD-DST) was developed to improve recognition of the causes. We undertook an evaluation of an electronic version of AiD-DST. Methods A development and evaluation life cycle of improvement was used. In phase 1, alpha testing among the development group evaluated technical performance of AiD-DST. In phase 2, we performed a cycle of beta testing among junior doctors to assess impressions of AiD-DST using Think Aloud methodology. We grouped responses into themes and made changes to AiD-DST by the development group accordingly. In phase 3, usability and acceptance of AiD-DST was assessed using the mHealth App Usability Questionnaire (MAUQ). Results In phase 1, software issues were identified, and modifications made. In phase 2, feedback was obtained from 29 junior doctors. Three cycles of feedback were obtained. The number of items identified after each cycle were 20, 12 and 7, respectively. Content was grouped into themes of; ‘style and grammar’, ‘formatting’, ‘IT’, ‘missed diagnosis’ and ‘other concerns.’ In phase 3, 20 participants completed MAUQ questionnaire. Overall, the average score was 6.36 (SD=0.8) with 7 as the highest attainable score. This translates to agreement up to strong agreement concerning usability of AiD-DST. Conclusion After a process of optimisation, AiD-DST has been shown to be a usable and potentially useful diagnostic support tool to help junior doctors identify cause(s) of delirium. An implementation study is planned.

Implementation of a pilot electronic parent support tool in and after neonatal intensive care unit discharge.

ObjectiveTo describe an electronic parent support tool for the neonatal intensive care unit (NICU), and to assess whether support requests changed with staff availability.MethodsWe implemented secure text- or email-based parent support in the NICU and in the week after discharge. Questionnaires asked whether a parent would like psychology, social work, child life, chaplain, or post-discharge nurse support. Requested referrals were placed, and customized online resources and contacts were provided. We assessed whether requests changed based on in-person resource availability.ResultsOf 378 infants in our NICU from May to December, 202 parents agreed to participate. The proportion agreeing to participate increased over time (38–59%, p = 0.012). Post-discharge nurse requests decreased over time (90–45%, p = 0.033); other requests did not change significantly.ConclusionsAn electronic tool increased parent support availability in the NICU and following discharge, even after staff were available at the bedside.

Use of a Smartphone Medication Reminder Application to Support Emerging Adult Adherence to Non-Antibiotic Treatment for Viral Upper Respiratory Tract Infection.

Objective:This research study is a test of the efficacy of a smartphone-installed medication reminder application to support provider-recommended treatment plans for young adult patients who were seen for upper respiratory tract infections (URTIs) and were not prescribed an antibiotic.Methods:Two hundred seventy-five patients seen at a university student health center for URTI symptoms were randomly assigned to the medication reminder app intervention or a control group and then surveyed both 1 and 14 days after their medical visits with questions about the treatment plan, their satisfaction with medical care, and the electronic support tools.Results:Compared to the control condition, patients using the reminder app reported more adherence to provider-recommended treatment plans. Patients with lower social support availability benefited more from being provided with these tools.Conclusion:These findings suggest that medication reminder apps have utility for increasing patient adherence to non-antibiotic URTI treatment plans, particularly among patients who lack high-quality informational and tangible social support.Innovation:This study demonstrates innovation in use of the medication reminder app to promote antibiotic stewardship with young adult patients in primary care.

Development and implementation of an online platform for curriculum mapping in medical education

Abstract Objectives Nowadays universities face ever-increasing demands on quality of education, which is crucial from perspective of future graduates. In face of the need of constant quality improvements of medical curricula, it is important to seek strategies for their efficient management. The general trend is to develop electronic support tools to streamline the curricular design, analysis and harmonization. Methods Based on the requirements we have identified by the needs analysis among curriculum designers, teachers and managers at five universities involved in the Building Curriculum Infrastructure in Medical Education (BCIME) project, and evidence published in literature on curriculum development, we have developed methodological guidelines on curriculum innovations and a software-based tools that help manage, map and analyse curricula in the medical and healthcare study fields. Results In this paper, we share our experiences with building and implementation of EDUportfolio, an online platform developed within our consortium and intended to facilitate harmonisation and optimisation of medical outcome-based curricula. Its functionalities and outputs were verified by pilot mapping of Anatomy curricula as taught at partner universities in five European countries. Conclusions The visualisation and the analysis of described curriculum data using natural language processing techniques revealed both the hidden relations between curriculum building blocks and a set of overlaps and gaps in curricula. In addition, we demonstrate both the usability of the platform in the context of the involved academic environments and the capability to map and compare curricula across different institutions and different countries.

Obérisk: Cybersecurity Requirements Elicitation through Agile Remote or Face-to-Face Risk Management Brainstorming Sessions

Cyberattacks make the news daily. Systems must be appropriately secured. Cybersecurity risk analyses are more than ever necessary, but… traveling and gathering in a room to discuss the topic has become difficult due to the COVID, whilst having a cybersecurity expert working isolated with an electronic support tool is clearly not the solution. In this article, we describe and illustrate Obérisk, an agile, cross-disciplinary and Obeya-like approach to risk management that equally supports face-to-face or remote risk management brainstorming sessions. The approach has matured for the last three years by using it for training and a wide range of real industrial projects. The overall approach is detailed and illustrated on a naval use case, with extensive feedback from the end-users. We show that Obérisk is really time-efficient and effective at managing risks at the early stages of a project, whilst remaining extremely low-cost. As the project grows or when the system is deployed, it may eventually be necessary to shift to a more comprehensive commercial electronic support tool.

The effectiveness of an electronic clinical-decision support tool embedded into the patient medical record at the point of care to guide Mohs surgery utilization: A cohort study

The effectiveness of an electronic clinical-decision support tool embedded into the patient medical record at the point of care to guide Mohs surgery utilization: A cohort study

Design and rationale for the "Me & My Heart" (eMocial) study: A randomized evaluation of a new smartphone-based support tool to increase therapy adherence of patients with acute coronary syndrome.

A novel smartphone‐based patient support tool was developed to increase the adherence to antiplatelet therapy and lifestyle changes in patients after coronary angioplasty for acute coronary syndrome (ACS). The eMocial study (http://clinicaltrials.gov Identifier: NCT02615704) investigates whether an electronic support tool will improve adherence to comedication and lifestyle changes in ACS patients. The primary hypothesis of this trial is that an electronic support tool can increase adherence to comedication (primary endpoint) thereby supporting positive lifestyle changes (secondary endpoints). Patients hospitalized with ACS (ST elevation myocardial infarction [STEMI], non‐ST elevation myocardial infarction [NSTEMI], or unstable angina pectoris) and treated with ticagrelor coadministered with low‐dose acetylsalicylic acid will be randomized 1:1 to an active group receiving the patient support tool via a smartphone‐based application or to a control group without the patient support tool. Patient questionnaires to evaluate lifestyle changes and quality of life will be used at baseline and at the end of the 48‐week observation phase. Patients are asked to fill out questionnaires to determine their adherence, treatment attitudes, health‐care utilization and risk factors on a monthly basis. The study was started in February 2016 and the completion date is scheduled for October 2019. For final analysis 664 patients are expected be available. Preliminary baseline demographics were unstable angina pectoris (13.7%), NSTEMI (49.9%), STEMI (36.4%), male gender (86.3%), and diabetes mellitus (17.6%). Our study could significantly help to understand how inadequate adherence to antiplatelet therapy in ACS patients could be improved with a smartphone‐based application.

Developing a Hospital-Wide Transition Program for Young Adults With Medical Complexity

PurposeTransitional age adults (18–24 years) are the fastest growing cohort of patients in children's hospitals across the nation. The purpose of the study was to standardize pediatric to adult healthcare transfers of complex adult patients through a tiered and multimodal population-based intervention. MethodsThe Multidisciplinary Intervention Navigation Team (MINT) was developed to decrease variations in pediatric to adult medical transitions. System-level goals were to (1) increase provider and leadership engagement, (2) increase transition tools, (3) increase use of electronic medical record–based clinical decision supports, (4) improve transition practices through development of transition policies and clinical pathways; (5) increase transition education for patients and caregivers; (6) increase the adult provider referral network; and (7) implement an adult transition consult service for complex patients (MINT Consult). ResultsBetween July 2015 and March 2017, MINT identified 11 transition champions, increased the number of divisions with drafted transition policies from 0 to 7, increased utilization of electronic medical record-based transition support tools from 0 to 7 divisions, held seven psychoeducational events, and developed a clinical pathway. MINT has received more than 70 patient referrals. Of patients referred, median age is 21 years (range, 17–43); 70% (n = 42) have an intellectual disability. Referring pediatric providers (n = 25) reported that MINT helped identify adult providers and coordinate care with other Children's Hospital of Philadelphia specialists (78%); and that MINT saved greater than 2 hours of time (48%). ConclusionsMINT improved the availability, knowledge, and use of transition-related resources; saved significant time among care team members; and increased provider comfort around transition-related conversations.

What Patients Want in a Smartphone App That Supports Colonoscopy Preparation: Qualitative Study to Inform a User-Centered Smartphone App.

BackgroundThe preparation for colonoscopy is elaborate and complex. In the context of colorectal cancer screening, up to 11% of patients do not keep their colonoscopy appointments and up to 33% of those attending their appointments have inadequately cleansed bowels that can delay cancer diagnosis and treatment. A smartphone app may be an acceptable and wide-reaching tool to improve patient adherence to colonoscopy.ObjectiveThe aim of this qualitative study was to employ a user-centered approach to design the content and features of a smartphone app called colonAPPscopy to support individuals preparing for their colonoscopy appointments.MethodsWe conducted 2 focus group discussions (FGDs) with gastroenterology patients treated at the McGill University Health Centre in Montreal, Canada. Patients were aged 50 to 75 years, were English- or French-speaking, and had undergone outpatient colonoscopy in the previous 3 months; they did not have inflammatory bowel disease or colorectal cancer. FGDs were 75 to 90 min, conducted by a trained facilitator, and audiotaped. Participants discussed the electronic health support tools they might use to help them prepare for the colonoscopy, the content needed for colonoscopy preparation, and the features that would make the smartphone app useful. Recordings of FGDs were transcribed and analyzed using thematic analysis to identify key user-defined content and features to inform the design of colonAPPscopy.ResultsA total of 9 patients (7 male and 2 female) participated in one of 2 FGDs. Main content areas focused on bowel preparation instructions, medication restrictions, appointment logistics, communication, and postcolonoscopy expectations. Design features to make the app useful and engaging included minimization of data input, reminders and alerts for up to 7 days precolonoscopy, and visual aids. Participants wanted a smartphone app that comes from a trusted source, sends timely and tailored messages, provides reassurance, provides clear instructions, and is simple to use.ConclusionsParticipants identified the need for postcolonoscopy information as well as reminders and alerts in the week before colonoscopy, novel content, and features that had not been included in previous smartphone-based strategies for colonoscopy preparation. The ability to tailor instructions made the smartphone app preferable to other modes of delivery. Study findings recognize the importance of including potential users in the development phase of building a smartphone app.

Considerations of Privacy and Confidentiality in Developing a Clinical Support Tool for Adolescent Tobacco Prevention: Qualitative Study.

BackgroundElectronic clinical support tools show promise for facilitating tobacco screening and counseling in adolescent well-care. However, the application of support tools in pediatric settings has not been thoroughly studied. Successfully implementing support tools in local settings requires an understanding of barriers and facilitators from the perspective of both patients and providers.ObjectiveThis paper aimed to present the findings of a qualitative study conducted to inform the development and implementation of a support tool for adolescent tobacco screening and counseling in 3 pediatric clinics in North Florida. The primary objective of the study was to test and collect information needed to refine a tablet-based support tool with input from patients and providers in the study clinics.MethodsA tablet prototype was designed to collect information from adolescents on tobacco susceptibility and use before their well-care visit and to present tobacco prevention videos based on their responses. Information collected from adolescents by the support tool would be available to providers during the visit to facilitate and streamline tobacco use assessment and counseling components of well-care. Focus groups with providers and staff from 3 pediatric clinics (n=24) identified barriers and facilitators to implementation of the support tool. In-depth interviews with racially and ethnically diverse adolescent patients who screened as susceptible to tobacco use (n=16) focused on acceptability and usability of the tool. All focus groups and interviews were audio-recorded and transcribed for team-based coding using thematic analysis.ResultsPrivacy and confidentiality of information was a salient theme. Both groups expressed concerns that the tool’s audio and visual components would impede privacy and that parents may read their child’s responses or exert control over the process. Nearly all adolescents stated they would be comfortable with the option to complete the tool at home via a Web portal. Most adolescents stated they would feel comfortable discussing tobacco with their doctor. Adolescent interviews elicited 3 emergent themes that added context to perspectives on confidentiality and had practical implications for implementation: (1) purity: an expressed lack of concern for confidentiality among adolescents with no reported history of tobacco use; (2) steadfast honesty: a commitment to being honest with parents and providers about tobacco use, regardless of the situation; and (3) indifference: a perceived lack of relevance of confidentiality, based on the premise that others will “find out anyway” if adolescents are using tobacco.ConclusionsThis study informed several modifications to the intervention to address confidentiality and introduce efficiency to well-care visits. The support tool was integrated into the electronic health record system used by the study clinics and modified to offer videos to all adolescents regardless of their tobacco use or susceptibility. Future studies will further test the acceptability of the intervention in practice.

Abstract 137: Using an Electronic Clinical Support Tool to Improve Anticoagulation in Patients with Atrial Fibrillation/Flutter

Background: It is estimated that atrial fibrillation (AF) impacts between 2.7 to 6.1 million American adults, and this is expected to double by 2050. The outpatient performance measures of the 2016 AHA/ACC Clinical Performance and Quality Measures include: Documentation of CHA2DS2-VASc Risk Score and anticoagulation (AC) prescription, when indicated. To address these outpatient measures, our team integrated a clinical support tool into our electronic medical record (EMR). Objectives: Our quality improvement project aimed to increase the percentage (or proportion) of patients with atrial fibrillation/flutter (AF) who were appropriately prescribed AC in an academic cardiology clinic. Our outcome measure was the frequency our tool was either: acknowledged, cancelled, or completed. Methods: Baseline data was collected via retrospective chart review for patients with documented AF. With the assistance of information technology, we created a pop-up clinical tool in the EMR that recognized if the patient is prescribed AC and provided a semi-automated calculation of the CHA2DS2-VASc score. If the patient had CHA2DS2-VASc ≥ 2 and was not on AC, the tool prompted the physician to select either: a contraindication, refusal or prescribe AC. Before implementing the electronic tool, the cardiologists were educated on the new tool and made aware of future data collection. Results: Baseline data from April 2018 included 104 patients with AF, of which 57.7% were prescribed AC. The frequency of AC prescription for all AF over the next 3 months increased: 76% in May, 69% in June, 86% in July. For these 3 months, when the clinical decision tool was encountered: 69 - 72% of cardiologists cancelled, 11 - 22% acknowledged, and 9-17% used the tool. Conclusion: Our outcome measure to increase AC prescription was achieved following implementation of an electronic clinical tool even though the cardiologists often did not interact with the tool. Similar to prior literature on clinical support tools, the provider’s clinical proficiency plays a large role in use. The tool may have been successful by providing a clinical reminder about AC in these patients . Early results show sustainability in AC prescription. Our clinical tool is now being implemented into a primary care clinic and may have increased use in that setting.

Совершенствование инструментария электронной государственной поддержки предпринимательства

Совершенствование инструментария электронной государственной поддержки предпринимательства

Stakeholder Engagement in Developing an Electronic Clinical Support Tool for Tobacco Prevention in Adolescent Primary Care

Following guideline recommendations to promote tobacco prevention in adolescent primary care, we developed a patient-facing clinical support tool. The electronic tool screens patients for use and susceptibility to conventional and alternative tobacco products, and promotes patient–provider communication. The purpose of this paper is to describe the iterative stakeholder engagement process used in the development of the tool. During the pre-testing phase, we consulted with scientists, methodologists, clinicians, and Citizen Scientists. Throughout the development phase, we engaged providers from three clinics in focus groups. Usability testing was conducted via in-depth, cognitive interviewing of adolescent patients. Citizen Scientists (n = 7) played a critical role in the final selection of educational content and interviewer training by participating in mock-up patient interviews. Cognitive interviews with patients (n = 16) ensured that systems were in place for the feasibility trial and assessed ease of navigation. Focus group participants (n = 24) offered recommendations for integrating the tool into clinical workflow and input on acceptability and appropriateness, and anticipated barriers and facilitators for adoption and feasibility. Engaging key stakeholders to discuss implementation outcomes throughout the implementation process can improve the quality, applicability, and relevance of the research, and enhance implementation success.

Electronic decision support for treatment of hospitalized smokers: A qualitative analysis of physicians’ knowledge, attitudes, and practices

BackgroundWe recently demonstrated the ability of a suite of tools embedded in an electronic medical record (EMR) to improve tobacco cessation treatment for adult smokers admitted to the hospital. A randomized controlled trial conducted by our group demonstrated the ability of an EMR-embedded tobacco use disorder treatment tool, the Electronic Support Tool and Orders for the Prevention of Smoking (E-STOPS), to increase the identification and treatment of smokers, but its uptake varied among 126 physicians randomized to the intervention arm. The purpose of this study was to identify facilitators and barriers to using E-STOPS. MethodsSemi-structured individual interviews from a purposive sample of 12 hospitalist attending physicians and nine internal medicine residents who were randomized to the E-STOPS intervention were analyzed thematically. ResultsThree themes shaped E-STOPS use: the inpatient environment, prescriber attitudes and beliefs, and information needs. Overall, participants were pleased with E-STOPS, but had specific suggestions for improvements regarding the timing of the intervention, suppression logic, and additional decision support and training. A few had concerns about the clinical appropriateness of beginning treatment for tobacco dependence during a hospitalization and the proper role of the inpatient team in that treatment. ConclusionsTobacco dependence treatment for hospitalized smokers and facilitated by the EMR is generally acceptable to hospitalists and resident physicians. Improvements in provider training and feedback as well as the timing and content of the electronic tools may increase their utilization by inpatient physicians.

Feasibility of implementing an electronic social support and resource visualization tool for caregivers in a neuro-oncology clinic.

The goals of this study were to assess the feasibility of a web-based application-electronic Social Network Assessment Program (eSNAP)-to automate the capture and visualization of family caregiver social network data of neuro-oncology patients. Caregivers were recruited from a neuro-oncology clinic at an NCI-designated comprehensive cancer center. Participants completed baseline questionnaires on a laptop in clinic assessing demographic characteristics. After baseline, participants were randomly assigned to either create a social network visualization using eSNAP (intervention) or to usual care (control) condition. Those who used eSNAP provided likeability/usability data. All participants were asked to complete follow-up questionnaires at 3 and 6weeks after baseline to determine feasibility of longitudinal study. We recruited 40 caregivers of patients with primary malignant brain tumor to participate in this study. Participants rated eSNAP usability and likeability highly, indicating that eSNAP would help them consider their available social support. At 3weeks, 90% of participants completed questionnaires and 82.5% completed questionnaires at 6weeks. There is a need to encourage family caregivers of patients with primary malignant brain tumor to engage their existing social network resources to help alleviate caregiver burden. Our findings suggest that our web-based application to address this issue is feasible to implement with high usability and likeability. This pilot study identified minor changes to the intervention to improve effectiveness and has implications for future research in this understudied population. clinicaltrials.gov, protocol number NCT03026699.

Addressing critical gaps in the treatment of eating disorders.

Remarkable progress has been made in developing psychosocial interventions for eating disorders and other mental disorders. Two priorities in providing treatment consist of addressing the research-practice gap and the treatment gap. The research-practice gap pertains to the dissemination of evidence-based treatments from controlled settings to routine clinical care. Closing the gap between what is known about effective treatment and what is actually provided to patients who receive care is crucial in improving mental health care, particularly for conditions such as eating disorders. The treatment gap pertains to extending treatments in ways that will reach the large number of people in need of clinical care who currently receive nothing. Currently, in the United States (and worldwide), the vast majority of individuals in need of mental health services for eating disorders and other mental health problems do not receive treatment. This article discusses the approaches required to better ensure: (1) that more people who are receiving treatment obtain high-quality, evidence-based care, using such strategies as train-the-trainer, web-centered training, best-buy interventions, electronic support tools, higher-level support and policy; and (2) that a higher proportion of those who are currently underserved receive treatment, using such strategies as task shifting and disruptive innovations, including treatment delivery via telemedicine, the Internet, and mobile apps.

Student perceptions of an online mathematics curriculum designed for students with learning difficulties

Paper presents research on the perception of technology use including dimensions of computer self-efficacy, motivation, and independence of use of electronic support tools of students with learning difficulties in the context of an online mathematics curriculum. While all students showed improvement over the course of the program, some students showed more success with technology-based learning than others. Students with stronger academic profiles when beginning the curriculum were more likely to have higher levels of computer self-efficacy. The themes that emerged from the current study reflect motivation and fun, efficiency, and a diversity of learning strategies and support tools available. The themes of motivation and independence are also reflected in electronic support tool use. This indicates that students with different motivating or independently themed factors use the program in different ways by tailoring the electronic support tools to their individual needs.

Students’ use of electronic support tools in mathematics

This study investigated students’ use of electronic support tools within a computer-based mathematics program. Electronic support tools are tools, such as hyperlinks or calculators, available within many computer-based instructional programs. A convenience sample of 73 students in grades 4–6 was selected to participate in the study. Students completed online lessons over the course of 6 weeks. Lessons were chosen to supplement the core instruction students’ received in their mathematics classes. Correlations were found between students’ use of specific electronic support tools and their basic academic skill fluency. A significant difference was also found between the pre and post mathematics test [t(72) = 6.463, p < .001, Cohen’s d = 1.52]. Structural equation modeling was used to examine the direct and indirect effects of prior academic skills (a latent variable comprised of working memory, math fact fluency, and reading rate) and the overall use of electronic support tools on gains between the pre and posttest. Results indicated that having stronger prior academic skills contributed to significantly lower levels of EST use for students, and having weaker prior academic skills contributed to significantly higher levels of EST use. EST use, in turn, positively predicted gains from the program, indicating an indirect effect of prior academic skills on gain scores.