Conversational Information Technology (IT) for Better, Safer Pediatric Primary Care (Massachusetts)

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Conversational Information Technology (IT) for Better, Safer Pediatric Primary Care - 2011

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    RFA: HS07-007: Ambulatory Safety and Quality Program: Enabling Patient-Centered Care through Health Information Technology (PCC)
  • Grant Number: 
    R18 HS 017248
  • Project Period: 
    September 2007 - August 2011
  • AHRQ Funding Amount: 
    $1,159,609
  • PDF Version: 
    (PDF, 191.29 KB)

Summary: This project developed and evaluated an automated telephony system as part of prevention services delivered in an urban pediatric practice. The system gathers personal health data and counsels parents before scheduled visits, integrates the data with the physician's electronic health record (EHR), and offers personalized followup assessment and counseling. The internally developed interactive voice response (IVR) telephony system interfaces with the providers' EHR. The telephony system, called the Personal Health Partner (PHP), uses fully automated, interactive conversations (including synthetic speech and speech recognition) to gather health data and counsel parents before scheduled pediatric primary care visits. Parent-entered data are shared with the child's primary care provider (PCP) via the EHR, where data are reviewed and clinician decision support is provided.

The system was evaluated via a three-armed randomized controlled trial (PHP only, PHP assessment with counseling, or usual care groups) to determine the marginal effect of the PHP intervention on comprehensive preventive and medication management assessments during PCP visits; preventive and medication management counseling; healthier parental behaviors; and increased parental activation.

Specific Aims:

  • Develop an automated telephony system that uses fully automated conversations to perform previsit pediatric primary care assessments, offer parental counseling (including appropriate medication use), and support clinician decisionmaking by incorporating the PHP child assessments into their EHR at the point-of-care. (Achieved)
  • Conduct a randomized clinical trial to determine: 1) whether PHP assessment alone (no counseling) with EHR data exchange leads to higher quality preventive care and medication management; and 2) whether the addition of PHP counseling to PHP child assessments (before and after visits) is associated with increased quality and healthier parental behaviors.(Achieved)

2011 Activities: Recruitment for the trial, which began in April 2009, continued through February 2011. Children aged 4 months to 11 years who were primary care patients at Boston Medical Center were eligible for the study. All patients with a primary care visit between June 2009 and February 2011 were invited to participate via a mailed brochure that provided information about participation in the study and how to call the PHP system. A data exchange was developed and implemented for the PHP telephony system and the EHR, and the hospital's clinical data warehouse was set up to deliver appointment and medication data into the team's SQL server database. The content of the PHP system includes three general areas: routine health care maintenance (RHCM), asthma symptom assessment, and medication safety. RHCM areas include: 1) general health supervision; 2) developmental screening; 3) diet and physical activity; 4) tuberculosis risk assessment; 5) smoking risk assessment; and 6) maternal depression screening. Participants were randomized into PHP only (n=74), PHP with counseling (n=290), and usual care (n=185). Once families began to use PHP successfully, providers were able to access this information in the EHR, and determine whether to accept the information to prepopulate the visit documentation.

Full implementation of the study protocol included printing and mailing of brochures using the PHP Manager (a PowerBuilder application), outbound calling, full implementation of the PHP patient-centered system, data exchange between the PHP system and the EHR, and completion of followup surveys.

Primary outcome measures were designed to assess whether patients received the appropriate care for prevention, treatment, and management. Parent- and provider-reported feasibility and acceptability were assessed via questionnaires developed by the study group and focused on usability, perceived value and effectiveness, and recommendation to others. Parent activation was assessed using a modified version of the 13-question Patient Activation Measure instrument. The instrument was modified to reflect activation from the point of view of a parent. Parental health literacy was assessed using the Rapid Estimate of Adult Literacy in Medicine, a valid test of word pronunciation that correlates with tests that evaluate a range of literacy skills.

As last self-reported in the AHRQ Research Reporting System, some project activities were on track while others were not, and project spending was on track. However, using a 1-year no-cost extension period, the team was able to extend the subject recruitment period and achieve all study aims. This project ended in August 2011.

Impact and Findings: PHP was able to identify and counsel in multiple areas. PHP parents were more likely to report discussing important issues such as depression and prescription medication use with their clinicians during visits. PHP parents were also more likely to report being better prepared for visits. Most PHP parents (89 percent) would recommend use of PHP to other parents. Use of a patient-centered IVR system such as PHP before routine health care maintenance visits can facilitate more comprehensive information at visits, identifying and counseling parents who have important issues, and better preparing parents and clinicians for visits. Systems like PHP have the potential to improve health-related behaviors, detect patient safety situations, and enhance patients' experience and engagement in primary care settings.

Target Population: Medically Underserved, Pediatric*

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Implementation and Use

* This target population is one of AHRQ's priority populations.

Conversational Information Technology for Better, Safer Pediatric Primary Care - 2010

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    RFA: HS07-007: Ambulatory Safety and Quality Program: Enabling Patient-Centered Care through Health Information Technology (PCC)
  • Grant Number: 
    R18 HS 017248
  • Project Period: 
    September 2007 – August 2011, Including No-Cost Extension
  • AHRQ Funding Amount: 
    $1,159,609
  • PDF Version: 
    (PDF, 722.5 KB)


Target Population: Medically Underserved, Pediatric*

Summary: This project seeks to develop and evaluate an automated telephony system as part of prevention services delivered in an urban pediatric practice. The system gathers personal health data and counsels parents before scheduled visits, integrates the data with the physician’s electronic health record (EHR), and offers personalized followup assessment and counseling after visits. The internally developed interactive voice response (IVR) telephony system interfaces with the providers’ EHR, GE Centricity Physician Office. The telephony system, called the Personal Health Partner (PHP), uses fully automated, interactive conversations (including synthetic speech and speech recognition) to gather health data and counsel parents before scheduled pediatric primary care visits. Parent-entered data are shared with the child’s primary care provider (PCP) via the EHR, where data are reviewed and clinician decision support is provided. The system is being evaluated via a three-armed randomized controlled trial (PHP only, PHP assessment with counseling, or usual care groups) to determine the marginal effect of the PHP intervention on: comprehensive preventive and medication management assessments during PCP visits; preventive and medication management counseling; healthier parental behaviors; and increased parental activation.

Specific Aims:
  • Develop an automated telephony system that uses fully automated conversations to perform pre-visit pediatric primary care assessments, offer parental counseling (including appropriate medication use), and support clinician decisionmaking by incorporating the PHP child assessments into their EHR at the point-of-care. (Achieved)
  • Conduct a randomized clinical trial to determine: 1) whether PHP assessment alone (no counseling) with EHR data exchange leads to higher quality preventive care and medication management, and 2) whether the addition of PHP counseling to PHP child assessments (before and after visits) is associated with increased quality and healthier parental behaviors. (Ongoing)

2010 Activities: Data exchange between the PHP telephony system and the EHR is complete, and the system is now fully operational. The hospital’s clinical data warehouse continues to deliver appointment and medication data into the team’s SQL Server database. Families are using PHP successfully and providers are able to access this information in the EHR. Providers can review the data provided by parents and determine whether to accept the information to prepopulate the visit documentation.

The grant team is using the PHP Manager (a PowerBuilder application) to print recruitment letters, appointment labels, and mailing labels. They have been actively recruiting participants since April 2009, and plan to continue recruitment through February 2011. Recruitment strategy improvements, including outbound reminder calls (initiated in late 2009) and increases in participant reimbursement (starting in September 2010), have continued to improve recruitment rates.

Grantee’s Most Recent Self-Reported Quarterly Status (as of December 2010): Active recruitment continued throughout 2010, and recruitment rates have continued to increase. The team remains approximately six months behind the original project schedule. Using no-cost extension funds, the team has extended the subject recruitment period and fully expects to achieve all study aims. Most milestones are being met, and there is a viable plan for achieving the others. Budget spending is roughly on target.

Preliminary Impact and Findings: Preliminary analyses, presented at the 2010 American Medical Informatics Association Conference in a poster titled, The Personal Health Partner: Conversational IT for Better, Safer Pediatric Primary Care, indicate that use of a patient-centered IVR system such as PHP before routine health care maintenance visits can lead to more comprehensive information at visits, identifying and counseling parents with important issues, and better preparing parents and clinicians for visits. Such systems have the potential to improve quality and efficiency in primary care settings.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Implementation and Use

*AHRQ Priority Population.

Project Details - Ended

Project Categories

Summary:

Throughout the health care system there are gaps between recommended care and the care that is actually provided to adults and children. One way to help close this gap for children is to better understand how families manage their medications at home. The use of interactive telephony technologies can be used in a patient-centric manner to help guide parents through interactive discussions to gather information while reinforcing recommendations and treatments for children.

This project evaluated whether an interactive voice response (IVR) system called the Personal Health Partner (PHP) used by parents prior to routine health maintenance visits could improve parental activation, the comprehensiveness of care provided, and medication safety. The PHP system addresses three core areas of parental activation: 1) having the confidence and knowledge necessary to take action; 2) actually taking action to maintain and improve their children’s health; and 3) staying the course even under stress. The PHP is a fully automated system that uses synthetic text-to-speech and automatic speech recognition to gather health data and counsel parents. 

The main objectives of this project were to:

  • Develop an automated telephony system that uses fully automated conversations to perform previsit pediatric primary care assessments, offer parental counseling (including appropriate medication use), and support clinician decisionmaking by incorporating the PHP child assessments into their electronic health record (EHR) at the point-of-care.
  • Conduct a randomized clinical trial to determine: 1) whether PHP assessment alone (no counseling) with EHR data exchange leads to higher-quality preventive care and medication management; and 2) whether the addition of PHP counseling to PHP child assessments (before and after visits) is associated with increased quality and healthier parental behaviors. 

A randomized trial was used to evaluate the PHP in a busy pediatric primary care office at Boston Medical Center. Parents who had scheduled an annual well-child exam were contacted via a mailed brochure and invited to participate. Those who were interested were asked to call the PHP anytime before the day of the appointment. At the time of their call they were randomized to PHP use, PHP use without counseling, or to usual care consisting of a safety assessment. Content for the calls included information on medication safety, diet and activity, parental smoking and depression, tuberculosis screening, developmental screening, and home safety. A week after the appointment, parents were asked to complete a followup assessment over the phone. At the end of the study providers completed an assessment via email.

PHP successfully identified and counseled parents. Those parents who used PHP were found to be more likely to discuss issues such as depression and medication use with their clinicians than those who did not use PHP. PHP parents also reported that they felt better prepared for visits with their children’s providers, and the majority indicated they would recommend PHP to other parents. The project team concluded that these systems have the potential to improve health-related behaviors, detect concerning patient safety situations, and enhance patients’ experience and engagement with care.

Conversational Information Technology (IT) for Better, Safer Pediatric Primary Care - Final Report

Citation:
Adams WG. Conversational Information Technology (IT) for Better, Safer Pediatric Primary Care - Final Report. (Prepared by Boston Medical Center under Grant No. R18 HS017248). Rockville, MD: Agency for Healthcare Research and Quality, 2012. (PDF, 593.97 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
Principal Investigator: 
Document Type: 
Medical Condition: 
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This project does not have any related emerging lesson.