Table 2 Design themes (n = 10 interviewees)

Barriers to establishing healthy lifestyles

• Limited access to healthy food (6)

• Limited access to exercise options (6)

• Health literacy (6)

• Multiple competing priorities (4)

• Cost (5)

• Lack of time to cook well, exercise (4)

• Cooking and food storage facilities, homelessness (3)

• Motivation (4)

• Culture/family (2)

Features of lifestyle modification program

• In-clinic contact for warm handoff (8)

• Community-based program (5)

• Cultural, language sensitivity (4)

• Economic sensitivity (2)

• Education provided pictorially (2)

• Physical activity facilitation – pedometer (2)

• Incentives to participate (2)

• Integrate with PCP for synergy in messaging (3)

• Social experience/support, peer network (1)

• Help patient set small realistic goals (1)

• Makes it easy to keep coming back (1)

• Remote component – phone/online (1)

• Provide stress management/coping skills counseling (1)

• Outcome/evidence based (1)

• Scalable/few resources/automated in some way (1)

• Identify patient and MD goals – work toward mutual goals (1)

Reporting of outcomes to primary care provider

• Patient identified goals (5)

• Patient’s level of engagement (7)

• Biometric data – weight, blood pressure, hemoglobin A1c (6)

• Patient’s barriers, red flags that would make success near impossible (6)

• Overall sense of progress (7)

• How patient relates choices to health outcomes (1)

• Food group breakdown versus fat/carbohydrate breakdown (2)

• Patient’s action plan (1)

Integration with primary care

• Quarterly updates (6)

• Access and use in real-time with patients (7)

• Provider alerts for new data (2)

• Display in the EHR: graphical display, access coaching notes, patient goals and barriers (10)

• Train ancillary staff to use data with patients (7)

• Way to acknowledge receipt (1)