Perspectives of family physicians on computer-assisted health-risk assessments

Screening tools for employment in clinical healthcare delivery systems: a content analysis

BACKGROUND

The relationship between work and health is complex and bidirectional, where work can have both health-harming and health-enhancing effects. Though employment is recognized as a social determinant of health, and clinical healthcare delivery systems are increasingly using screening tools to ask patients about social needs, little research has explored the extent to which employment-related social risk is captured in these screening tools. This study aimed to identify and characterize employment- and work-related questions in social risk screening tools that have been implemented in clinical healthcare delivery systems.

METHODS

We conducted a qualitative content analysis of employment-related items in screening tools that have been implemented in clinical healthcare service delivery systems. Three content areas guided data extraction and analysis: Setting, Domain, and Level of Contextualization.

RESULTS

Screening tools that asked employment-related questions were implemented in settings that were diverse in the populations served and the scope of care provided. The intent of employment-related items focused on four domains: Social Risk Factor, Social Need, Employment Exposure, and Legal Need. Most questions were found to have a low Level of Contextualization and were largely focused on identifying an individual's employment status.

CONCLUSIONS

Several existing screening tools include measures of employment-related social risk, but these items do not have a clear purpose and range widely depending on the setting in which they are implemented. In order to maximize the utility of these tools, clinical healthcare delivery systems should carefully consider what domain(s) they aim to capture and how they anticipate using the screening tools to address social determinants of health.

Workload and workflow implications associated with the use of electronic clinical decision support tools used by health professionals in general practice: a scoping review

BACKGROUND

Electronic clinical decision support tools (eCDS) are increasingly available to assist General Practitioners (GP) with the diagnosis and management of a range of health conditions. It is unclear whether the use of eCDS tools has an impact on GP workload. This scoping review aimed to identify the available evidence on the use of eCDS tools by health professionals in general practice in relation to their impact on workload and workflow.

METHODS

A scoping review was carried out using the Arksey and O'Malley methodological framework. The search strategy was developed iteratively, with three main aspects: general practice/primary care contexts, risk assessment/decision support tools, and workload-related factors. Three databases were searched in 2019, and updated in 2021, covering articles published since 2009: Medline (Ovid), HMIC (Ovid) and Web of Science (TR). Double screening was completed by two reviewers, and data extracted from included articles were analysed.

RESULTS

The search resulted in 5,594 references, leading to 95 full articles, referring to 87 studies, after screening. Of these, 36 studies were based in the USA, 21 in the UK and 11 in Australia. A further 18 originated from Canada or Europe, with the remaining studies conducted in New Zealand, South Africa and Malaysia. Studies examined the use of eCDS tools and reported some findings related to their impact on workload, including on consultation duration. Most studies were qualitative and exploratory in nature, reporting health professionals' subjective perceptions of consultation duration as opposed to objectively-measured time spent using tools or consultation durations. Other workload-related findings included impacts on cognitive workload, "workflow" and dialogue with patients, and clinicians' experience of "alert fatigue".

CONCLUSIONS

The published literature on the impact of eCDS tools in general practice showed that limited efforts have focused on investigating the impact of such tools on workload and workflow. To gain an understanding of this area, further research, including quantitative measurement of consultation durations, would be useful to inform the future design and implementation of eCDS tools.

Patient perspectives on tablet-based technology to collect risk factor information in primary care

BACKGROUND

Primary care provides an opportunity to introduce prevention strategies and identify risk behaviours. Algorithmic information technology such as the Risk Factor Identification Tool (RFIT) can support primary care counseling. This study explores the integration of the tablet-based RFIT in primary care clinics to support exploration of patient risk factor information.

METHODS

Qualitative study to explore patients' perspectives of RFIT. RFIT was implemented in two primary care clinics in Manitoba, Canada. There were 207 patients who completed RFIT, offered to them by eight family physicians. We conducted one-on-one patient interviews with 86 patients to capture the patient's perspective. Responses were coded and categorized into five common themes.

RESULTS

RFIT had a completion rate of 86%. Clinic staff reported that very few patients declined the use of RFIT or required assistance to use the tablet. Patients reported that the tablet-based RFIT provided a user-friendly interface that enabled self-reflection while in the waiting room. Patients discussed the impact of RFIT on the patient-provider interaction, utility for the clinician, their concerns and suggested improvements for RFIT. Among the patients who used RFIT 12.1% smoked, 21.2% felt their diet could be improved, 9.3% reported high alcohol consumption, 56.4% reported less than 150 min of PA a week, and 8.2% lived in poverty.

CONCLUSION

RFIT is a user-friendly tool for the collection of patient risk behaviour information. RFIT is particularly useful for patients lacking continuity in the care they receive. Information technology can promote self-reflection while providing useful information to the primary care clinician. When combined with practical tools and resources RFIT can assist in the reduction of risk behaviours.

Using Information Technology to Assess Patient Risk Factors in Primary Care Clinics: Pragmatic Evaluation

BACKGROUND

Tobacco use, physical inactivity, and poor diet are associated with morbidity and premature death. Health promotion and primary prevention counseling, advice, and support by a primary care provider lead to behavior change attempts among patients. However, although physicians consider preventative health important, there is often a larger focus on symptom presentation, acute care, and medication review.

OBJECTIVE

This study evaluated the feasibility, adoption, and integration of the tablet-based Risk Factor Identification Tool (RFIT) that uses algorithmic information technology to support obtainment of patient risk factor information in primary care clinics.

METHODS

This is a pragmatic developmental evaluation. Each clinic developed a site-specific implementation plan adapted to their workflow. The RFIT was implemented in 2 primary care clinics located in Manitoba. Perceptions of 10 clinic staff and 8 primary care clinicians informed this evaluation.

RESULTS

Clinicians reported a smooth and fast transfer of RFIT responses to an electronic medical record encounter note. The RFIT was used by 207 patients, with a completion rate of 86%. Clinic staff reported that approximately 3%-5% of patients declined the use of the RFIT or required assistance to use the tablet. Among the 207 patients that used the RFIT, 22 (12.1%) smoked, 39 (21.2%) felt their diet could be improved, 20 (12.0%) reported high alcohol consumption, 103 (56.9%) reported less than 150 minutes of physical activity a week, and 6 (8.2%) patients lived in poverty. Clinicians suggested that although a wide variety of patients were able to use the tablet-based RFIT, implemented surveys should be tailored to patient subgroups.

CONCLUSIONS

Clinicians and clinic staff positively reviewed the use of information technology in primary care. Algorithmic information technology can collect, organize, and synthesize individual health information to inform and tailor primary care counseling to the patients' context and readiness to change. The RFIT is a user-friendly tool that provides an effective method for obtaining risk factor information from patients. It is particularly useful for subsets of patients lacking continuity in the care they receive. When implemented within a context that can support practical interventions to address identified risk factors, the RFIT can inform brief interventions within primary care.

Health Risk Assessments in Michigan's Medicaid Expansion: Early Experiences in Primary Care

INTRODUCTION

Michigan is one of 3 states that have implemented health risk assessments for enrollees as a feature of its Medicaid expansion, the Healthy Michigan Plan. This study describes primary care providers' early experiences with completing health risk assessments with enrollees and examines provider- and practice-level factors that affect health risk assessment completion.

METHODS

All primary care providers caring for ≥12 Healthy Michigan Plan enrollees (n=4,322) were surveyed from June to November 2015, with 2,104 respondents (55.5%). Analyses in 2016-2017 described provider knowledge, attitudes, and experiences with the health risk assessment early in Healthy Michigan Plan implementation; multivariable analyses examined relationships of provider- and practice-level characteristics with health risk assessment completion, as recorded in state data.

RESULTS

Of the primary care provider respondents, 73% found health risk assessments very or somewhat useful for identifying and discussing health risks, although less than half (47.2%) found them very or somewhat useful for getting patients to change health behaviors. Most primary care provider respondents (65.3%) were unaware of financial incentives for their practices to complete health risk assessments. Nearly all primary care providers had completed at least 1 health risk assessment. The mean health risk assessment completion rate (completed health risk assessments/number of Healthy Michigan Plan enrollees assigned to that primary care provider) was 19.6%; those who lacked familiarity with the health risk assessment had lower completion rates.

CONCLUSIONS

Early in program implementation, health risk assessment completion rates by primary care providers were low and awareness of financial incentives limited. Most primary care provider respondents perceived health risk assessments to be very or somewhat useful in identifying health risks, and about half of primary care providers viewed health risk assessments as very or somewhat useful in helping patients to change health behaviors.

The development of a theory-based eHealth app prototype to promote oral health during prenatal care visits

Poor maternal oral health during pregnancy is associated with adverse maternal and child outcomes, including preterm birth and early childhood caries. Subsequently, professional associations have developed prenatal oral health guidelines, but significant gaps exist in implementing guidelines into clinical practice. The purpose of this study was to develop and test the usability of an innovative, theory-driven, eHealth application ("app") to facilitate prenatal providers' (nurse practitioners and midwives) implementation of oral health promotion during prenatal care visits. App development was guided by previous research, an integrated conceptual framework, Scientific Advisory Board input, and consumer-engaged iterative processes utilizing mixed-methods (observations, surveys, in-depth interviews) among providers (n = 4) during 10 unique prenatal care visits at a federally qualified health care center. Triangulation of quantitative and qualitative data analysis produced descriptive frequencies and salient themes. Concepts and principles from the following theoretical frameworks informed intervention development and testing: Consolidated Framework for Implementation Research; Information-Motivation-Behavioral Skills Model; Health Literacy; and Brief Motivational Interviewing. Overall, providers reported the app was effective at providing the information, motivation, and behavioral skills needed to integrate oral health promotion (e.g., easy to use; provided cues to action via scripts and tailored education; and documented findings into the patient's record). Although providers reported high usability, time constraints and detailed patient counseling scripts were identified areas for improvement. Findings suggest that the eHealth app could serve as an innovative mechanism to assist providers in implementing the prenatal oral health guidelines into practice. Future research is needed to continue app development efforts and to determine efficacy and effectiveness in practice settings.

Brief Motivational Interviewing Delivered by Clinician or Computer to Reduce Sexual Risk Behaviors in Adolescents: Acceptability Study

BACKGROUND

Clinicians are expected to screen their adolescent patients for an increasing number of health behaviors and intervene when they uncover risky behaviors, yet, the clinic time allotted to screen, intervene, and provide resources is insufficient. Brief motivational interviewing (MI) offers succinct behavior change counseling; however, for implementation, clinicians need training, skill, and time. Computerized screening and counseling adjuvants may help clinicians increase their scope of behavioral screening, especially with sensitive topics such as sexual health, and provide risk-reduction interventions without consuming provider time during visits.

OBJECTIVE

The objectives of this study were to (1) understand the extent to which health care providers use brief MI for sexual health discussions with adolescent patients and (2) assess the acceptability of incorporating a brief MI-based intervention to reduce sexual risk behaviors into their clinical practice delivered by either themselves or a computer.

METHODS

At a national medical conference, surveys were administered to clinicians who provide sexual health care to adolescents. They were asked about their current use of MI for sexual risk behavior discussions and their willingness to implement computerized sexual health screening and computerized sexual risk behavior interventions into their clinical practice.

RESULTS

The large majority (87.6%, 170/194) of clinicians already used MI with their patients with less than half (72/148, 48.6%) reporting they had been formally trained in MI. Despite all (195/195, 100.0%) clinicians feeling very or completely comfortable discussing sexual risk behaviors with their patients, the large majority (160/195, 82.1%) reported it would be useful, very useful, or extremely useful for a computerized program to do it all: screen their patients, generate risk profiles, and provide the risk-reduction counseling rather than doing it themselves.

CONCLUSIONS

In this study, most clinicians used some form of brief MI or client-centered counseling when discussing sexual risk behaviors with adolescents and are very comfortable doing so. However, the large majority would prefer to implement computerized sexual health screening, risk assessment, and sexual risk behavior interventions into their clinical care of adolescents.

Comprehensive process model of clinical information interaction in primary care: results of a "best-fit" framework synthesis

Objective

To describe a new, comprehensive process model of clinical information interaction in primary care (Clinical Information Interaction Model, or CIIM) based on a systematic synthesis of published research.

Materials and Methods

We used the "best fit" framework synthesis approach. Searches were performed in PubMed, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Library and Information Science Abstracts, Library, Information Science and Technology Abstracts, and Engineering Village. Two authors reviewed articles according to inclusion and exclusion criteria. Data abstraction and content analysis of 443 published papers were used to create a model in which every element was supported by empirical research.

Results

The CIIM documents how primary care clinicians interact with information as they make point-of-care clinical decisions. The model highlights 3 major process components: (1) context, (2) activity (usual and contingent), and (3) influence. Usual activities include information processing, source-user interaction, information evaluation, selection of information, information use, clinical reasoning, and clinical decisions. Clinician characteristics, patient behaviors, and other professionals influence the process.

Discussion

The CIIM depicts the complete process of information interaction, enabling a grasp of relationships previously difficult to discern. The CIIM suggests potentially helpful functionality for clinical decision support systems (CDSSs) to support primary care, including a greater focus on information processing and use. The CIIM also documents the role of influence in clinical information interaction; influencers may affect the success of CDSS implementations.

Conclusion

The CIIM offers a new framework for achieving CDSS workflow integration and new directions for CDSS design that can support the work of diverse primary care clinicians.

A Model of Organizational Context and Shared Decision Making: Application to LGBT Racial and Ethnic Minority Patients

Shared decision making (SDM) occurs when patients and clinicians work together to reach care decisions that are both medically sound and responsive to patients' preferences and values. SDM is an important tenet of patient-centered care that can improve patient outcomes. Patients with multiple minority identities, such as sexual orientation and race/ethnicity, are at particular risk for poor SDM. Among these dual-minority patients, added challenges to clear and open communication include cultural barriers, distrust, and a health care provider's lack of awareness of the patient's minority sexual orientation or gender identity. However, organizational factors like a culture of inclusion and private space throughout the visit can improve SDM with lesbian, gay, bisexual, and transgender ("LGBT") racial/ethnic minority patients who have faced stigma and discrimination. Most models of shared decision making focus on the patient-provider interaction, but the health care organization's context is also critical. Context-an organization's structure and operations-can strongly influence the ability and willingness of patients and clinicians to engage in shared decision making. SDM is most likely to be optimal if organizations transform their contexts and patients and providers improve their communication. Thus, we propose a conceptual model that suggests ways in which organizations can shape their contextual structure and operations to support SDM. The model contains six drivers: workflows, health information technology, organizational structure and culture, resources and clinic environment, training and education, and incentives and disincentives. These drivers work through four mechanisms to impact care: continuity and coordination, the ease of SDM, knowledge and skills, and attitudes and beliefs. These mechanisms can activate clinicians and patients to engage in high-quality SDM. We provide examples of how specific contextual changes could make SDM more effective for LGBT racial/ethnic minority populations, focusing especially on transformations that would establish a safe environment, build trust, and decrease stigma.

Don't Forget the Doctor: Gastroenterologists' Preferences on the Development of mHealth Tools for Inflammatory Bowel Disease

Background

Inflammatory bowel disease (IBD) encompasses a number of disorders of the gastrointestinal tract. Treatment for IBD is lifelong and complex, and the majority of IBD patients seek information on the Internet. However, research has found existing digital resources to be of questionable quality and that patients find content lacking. Gastroenterologists are frontline sources of information for North American IBD patients, but their opinions and preferences for digital content, design, and utility have not been investigated. The purpose of this study is to systematically explore gastroenterologists’ perceptions of, and design preferences for, mHealth tools.

Objective

Our goal was to critically assess these issues and elicit expert feedback by seeking consensus with Canadian gastroenterologists.

Methods

Using a qualitative approach, a closed meeting with 7 gastroenterologists was audio recorded and field notes taken. To synthesize results, an anonymous questionnaire was collected at the end of the session. Participant-led discussion themes included methodological approaches to non-adherence, concordance, patient-centricity, and attributes of digital tools that would be actively supported and promoted.

Results

Survey results indicated that 4 of the 7 gastroenterologists had experienced patients bringing digital resources to a visit, but 5 found digital patient resources to be inaccurate or irrelevant. All participants agreed that digital tools were of increasing importance and could be leveraged to aid in consultations and save time. When asked to assess digital attributes that they would be confident to refer patients to, all seven indicated that the inclusion of evidence-based facts were of greatest importance. Patient peer-support networks were deemed an asset but only if closely monitored by experts. When asked about interventions, nearly all (6/7) preferred tools that addressed a mix of compliance and concordance, and only one supported the development of tools that focused on compliance. Participants confirmed that they would actively refer patients and other physicians to digital resources. However, while a number of digital IBD tools exist, gastroenterologists would be reluctant to endorse them.

Conclusions

Gastroenterologists appear eager to use digital resources that they believe benefit the physician-patient relationship, but despite the trend of patient-centric tools that focus on concordance (shared decision making and enlightened communication between patients and their health care providers), they would prefer digital tools that highlight compliance (patient following orders). This concordance gap highlights an issue of disparity in digital health: patients may not use tools that physicians promote, and physicians may not endorse tools that patients will use. Further research investigating the concordance gap, and tensions between physician preferences and patient needs, is required.

Screening women for intimate partner violence in healthcare settings

BACKGROUND

Intimate partner violence (IPV) damages individuals, their children, communities, and the wider economic and social fabric of society. Some governments and professional organisations recommend screening all women for intimate partner violence rather than asking only women with symptoms (case-finding); however, what is the evidence that screening interventions will increase identification, and referral to support agencies, or improve women's subsequent wellbeing and not cause harm?

OBJECTIVES

To assess the effectiveness of screening for intimate partner violence conducted within healthcare settings for identification, referral to support agencies and health outcomes for women.

SEARCH METHODS

We searched the following databases in July 2012: CENTRAL (2012, Issue 6), MEDLINE (1948 to September Week June Week 3 2012), EMBASE (1980 to Week 28 2012), MEDLINE In-Process (3 July 2012), DARE (2012, Issue 2), CINAHL (1937 to current), PsycINFO (1806 to June Week 4 2012), Sociological Abstracts (1952 to current) and ASSIA (1987 to October 2010). In addition we searched the following trials registers: metaRegister of Controlled Trials (mRCT) (to July 2012), and International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov, Australian New Zealand Clinical Trials Registry and the International Standard Randomised Controlled Trial Number Register to August 2010. We also searched the reference lists of articles and websites of relevant organisations.

SELECTION CRITERIA

Randomised or quasi-randomised trials assessing the effectiveness of IPV screening where healthcare professionals screened women face-to-face or were informed of results of screening questionnaires, compared with usual care ( which included screening for other purposes).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the risk of bias in the trials and undertook data extraction. For binary outcomes, we calculated a standardised estimation of the risk ratio (RR) and for continuous data, either a mean difference (MD) or standardised mean difference (SMD). All are presented with a 95% confidence interval (CI).

MAIN RESULTS

We included 11 trials that recruited 13,027 women overall. Six of 10 studies were assessed as being at high risk of bias.When data from six comparable studies were combined (n = 3564), screening increased identification of victims/survivors (RR 2.33; 95% CI 1.40 to 3.89), particularly in antenatal settings (RR 4.26; 95% CI 1.76 to 10.31).Only three studies measured referrals to support agencies (n = 1400). There is no evidence that screening increases such referrals, as although referral numbers increased in the screened group, actual numbers were very small and crossed the line of no effect (RR 2.67; 95% CI 0.99 to 7.20).Only two studies measured women's experience of violence after screening (one at three months, the other at six, 12 and 18 months after screening) and found no significant reduction of abuse.Only one study measured adverse effects and data from this study suggested that screening may not cause harm. This same study showed a trend towards mental health benefit, but the results did not reach statistical significance.There was insufficient evidence on which to judge whether screening increases take up of specialist services, and no studies included economic evaluation.

AUTHORS' CONCLUSIONS

Screening is likely to increase identification rates but rates of referral to support agencies are low and as yet we know little about the proportions of false measurement (negatives or positives). Screening does not appear to cause harm, but only one study examined this outcome. As there is an absence of evidence of long-term benefit for women, there is insufficient evidence to justify universal screening in healthcare settings. Studies comparing screening versus case finding (with or without advocacy or therapeutic interventions) for women's long-term wellbeing would better inform future policies in healthcare settings.