Developing a human factors-informed onboarding workflow for digital health programs: lessons from a virtual type 2 diabetes self-management program

Participation in digital health programs often depends on successful setup and early use of digital tools, yet individuals with lower digital familiarity may encounter barriers during virtual onboarding. To support engagement in Closing The Loop (CTL), a virtual self-management program for type 2 diabetes (T2D), we developed and refined a structured approach to remote setup of devices and mobile applications. This paper describes the onboarding process, the barriers encountered during virtual setup, and how these observations informed a more systematic workflow for guided setup, troubleshooting, and verification of data-sharing during early program use. Individuals with T2D receiving care at the VA Connecticut Healthcare System were mailed a smartwatch and user guide before a scheduled virtual onboarding session. During onboarding, participants configured devices and mobile applications required for program participation. Participants completed a survey assessing demographic characteristics and self-reported digital health literacy using the eHealth Literacy Scale (eHEALS). Field notes from onboarding sessions were synthesized into case summaries to characterize onboarding experiences, identify common barriers, and inform iterative refinement of a more structured onboarding workflow. All 12 participants completed onboarding. Participants were 25% women, and 58% were aged 60 years or older. Common onboarding barriers included device syncing (42%), application permissions (42%), difficulty locating downloaded applications (25%), and inaccessible accounts (25%). Session duration ranged from under 20 minutes to over 60 minutes, with two-thirds of participants completing onboarding in 20 to 60 minutes. Case summaries suggested that participants with lower self-reported digital health literacy generally required more stepwise guidance and longer onboarding sessions. Observations from these sessions informed refinement of the onboarding process into the Structured Onboarding Session (SOS) and TechList, a more systematic workflow for guided setup, troubleshooting, and verification of data-sharing during early program use. This quality improvement project identified recurring barriers encountered during remote onboarding and informed development of a more systematic workflow for early setup of digital health tools. Findings underscore the importance of anticipatory troubleshooting, structured branching, and verification of actual data flow or task completion rather than installation alone. The SOS and TechList formalize onboarding as a structured implementation component within a virtual T2D self-management program. The resulting workflow may offer transferable design principles for digital health interventions that require device setup, account creation, data-sharing, or coordination across multiple apps and platforms.