eCHAT for Lifestyle and Mental Health Screening in Primary Care

Felicity Goodyear-Smith; Jim Warren; Minja Bojic; Angela Chong

doi:10.1370/afm.1512

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eCHAT: An excellent foundation for patient-centered primary care
Sallie Beth Johnson, MPH, MCHES

Published on: 06 February 2014
Author response: Chatting about eCHAT
Felicity A. Goodyear-Smith

Published on: 02 October 2013
Let's Chat about eChat
Gillian Bartlett

Published on: 01 October 2013

Published on: (6 February 2014)
Page navigation anchor for eCHAT: An excellent foundation for patient-centered primary care
eCHAT: An excellent foundation for patient-centered primary care
Sallie Beth Johnson, MPH, MCHES, Doctoral Scholar
Other Contributors:
The eCHAT study published by Goodyear-Smith and colleagues is an excellent example of the type of pragmatic research that is necessary to move the assessment of health behaviors and psychosocial issues into standard primary care practice. Dr. Goodyear-Smith and her colleagues selected clinics that varied in the populations served and we were impressed with the high eCHAT completion rate by patients. In addition, the mix...
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The eCHAT study published by Goodyear-Smith and colleagues is an excellent example of the type of pragmatic research that is necessary to move the assessment of health behaviors and psychosocial issues into standard primary care practice. Dr. Goodyear-Smith and her colleagues selected clinics that varied in the populations served and we were impressed with the high eCHAT completion rate by patients. In addition, the mixed methods approach that allowed both patients and physicians to comment on the process provided valuable data for future implementation of the tool (e.g., patient finding that yes/no answers may be too limiting, physician finding that using the tool to aid in patient-provider communications did not overburdened them). The study's findings also demonstrated promise for the feasibility and acceptability of electronic tools to conduct systematic lifestyle and mental health screening. Furthermore, the study exemplifies research that is needed to learn how to effectively engage patients, providers and practice staff with technologies to improve population health.
As noted by Bartlett in his TRACK comments, we also believe the eCHAT tool may be enhanced by expanding its domains. In the United States, through expert opinions and crowd sourcing, we harmonized patient-reported data elements for EHR inclusion[1]. Similar to the eCHAT study, we are testing the feasibility of incorporating these elements through a web-based tool called My Own Health Report (MOHR)[2]. In addition to eCHAT measures, the MOHR tool asks about diet (fruit/vegetable, fast food and sugar-sweetened beverage consumption), obesity, prescription drug abuse, stress, sleep and all forms of tobacco, not solely cigarettes. Still, the key similarities between eCHAT and MOHR are that they use pragmatic measures[3] that have strong face validity, are brief, and provide a physician with actionable information relative to a public health priority --and both have been deemed relevant by multiple stakeholders[2].
The next step proposed by Goodyear-Smith and colleagues is a trial to determine effectiveness and implementation costs. We strongly endorse the examination of costs and also encourage moving further down the explanatory/pragmatic continuum4 to examine the feasibility of the tool when delivered by practice-based personnel rather than research assistants. From the follow-up eCHAT data it appears that the number of assessments did not decrease significantly from the 196 patients assessed between November and February and the 20 completed eCHATs per week across the two clinics for up to 46 weeks follow-up. This is valuable information and we look forward to reading about the process used to shift implementation from research staff to the practice staff.
We also propose that further study on the reach of tools like eCHAT is necessary. While this trial was very promising, the number of completed assessments is difficult to interpret without a known denominator of the number of patients that would have been eligible, rather than the number that were invited. Finally, as health care systems continue to try to respond to changes related to the Affordable Care Act and move towards population health management, research that examines how these types of tools can be applied and acted upon outside of the traditional face-to-face clinical visits are needed.
In summary, we applaud the eCHAT study and welcome the much-needed discussion it brings to systematically addressing unhealthy behaviors and concerning mental health issues.
References: 1. Estabrooks PA, Boyle M, Emmons KM, Glasgow RE, Hesse BW, Kaplan RM, et al. Harmonized patient-reported data elements in the electronic health record: supporting meaningful use by primary care action on health behaviors and key psychosocial factors. Journal of the American Medical Informatics Association: JAMIA. 2012 Jul-Aug;19(4):575-82.
2. Krist AH, Glenn BA, Glasgow RE, Balasubramanian BA, Chambers DA, Fernandez ME, et al. Designing a valid randomized pragmatic primary care implementation trial: the my own health report (MOHR) project. Implementation Science: IS. 2013;8:73.
3. Glasgow RE, Riley WT. Pragmatic measures: what they are and why we need them. American Journal of Preventive Medicine. 2013 Aug;45(2):237-43.
4. Thorpe KE, Zwarenstein M,Oxman AD,Treweek S, Furberg CD, et al. A pragmatic-explanatory continuum indicator summary (PRECIS): a tool to help trial designers. Can Med Assoc J. 2009;180(10):E47-E57.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (2 October 2013)
Page navigation anchor for Author response: Chatting about eCHAT
Author response: Chatting about eCHAT
Felicity A. Goodyear-Smith, Professor
Bartlett correctly identifies that eCHAT is particularly apt for use in the elderly, who may have lifestyle issues including alcohol and drug use they are prepared to address should the topic be broached. eCHAT may also uncover incidents of elder abuse from carers. Family physicians may have known their patients for many years and raising eCHAT issues (smoking, drinking, other drug use, problematic gambling, depression,...
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Bartlett correctly identifies that eCHAT is particularly apt for use in the elderly, who may have lifestyle issues including alcohol and drug use they are prepared to address should the topic be broached. eCHAT may also uncover incidents of elder abuse from carers. Family physicians may have known their patients for many years and raising eCHAT issues (smoking, drinking, other drug use, problematic gambling, depression, anxiety, abuse, anger control and physical inactivity) might not arise in the consultation. Our experience from this pilot and from a recent partial roll-out of eCHAT to 30 practices is that doctors are sometimes surprised at what is revealed, and it stimulates a conversation about possible behavioral changes the patient may wish to make.
With an electronic format it is possible to have branching logic with added tools made available to targeted groups identified from the electronic health record. For example eCHAT for elderly patients who smoke could include a respiratory function tool.
There is no point in screening / case-finding unless appropriate interventions are then discussed and offered. The current version of eCHAT has integrated stepped care decision support (self-management options; clinician-provided medication prescriptions and brief interventions; appropriate community-based agencies and referral to secondary care providers).
However as Bartlett identifies, a randomized controlled trial (RCT) is needed to determine whether systematic use of eCHAT really does lead to improved health outcomes.
In the United Kingdom all low risk primary care patients aged 40 to 75 years (the elderly, over 75 years old are excluded) are offered fully funded "health checks" which screen for diabetes, chronic kidney disease, cardiovascular disease and stroke risk, assessment of alcohol consumption and dementia regardless of patients' risk profiles. A recent Cochrane review concluded however that health checks ("general population screening of more than one disease or risk factor in more than one organ system") neither reduce morbidity nor mortality.[1] I recently wrote in an editorial for the BMJ "While there may be good evidence for targeted screening of high-risk individuals, the generic approach of composite screens for the entire population may be producing many false positives and false negatives, not be value for money, and has the potential for harm."[2]
It remains to be seen whether the primary care use of patient-entered eCHAT pre-consultation for identification of mental health and lifestyle issues, coupled with assessing their help-seeking behavior and providing stepped care decision support, is effective in improving patients' health and well-being. We need an RCT to establish this and are hoping grant applications for funding will be successful.
References
1. Krogsboll LT, Jorgensen KJ, Gronhoj Larsen C, Gotzsche PC. General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. Bmj 2012; 345: e7191.
2. Goodyear-Smith F. Government's plans for universal health checks for people aged 40-75 Br Med J 2013; 347: f4788.
Competing interests: ?? None declared
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Competing Interests: None declared.
Published on: (1 October 2013)
Page navigation anchor for Let's Chat about eChat
Let's Chat about eChat
Gillian Bartlett, Associate Professor
Goodyear-Smith's study on the eChat tool was very encouraging to see as it demonstrated feasibility of an inexpensive self-administered tool for lifestyle and mood assessment. The tool which has been adapted for the iPad assesses smoking, drinking, other drug use, problematic gambling, depression, anxiety, abuse, anger control and physical inactivity. One of the key feature that the tool, as noted by the authors, is the...
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Goodyear-Smith's study on the eChat tool was very encouraging to see as it demonstrated feasibility of an inexpensive self-administered tool for lifestyle and mood assessment. The tool which has been adapted for the iPad assesses smoking, drinking, other drug use, problematic gambling, depression, anxiety, abuse, anger control and physical inactivity. One of the key feature that the tool, as noted by the authors, is the "Help" question, which assesses whether patients are ready to address specific eCHAT problem domains, thereby increasing the likelihood the patient will change behaviour. These types of tools that help patients and physicians implement systematic lifestyle and mental health screening in primary care are critical. What the authors of this study have begun to demonstrate is that it is also feasible.
The demographic and epidemiological transformation of the North American population is well documented. The proportion of seniors in the population is expected to double by 2025. In addition, more of the elderly are developing multiple chronic diseases and are living longer with those diseases. [1-4] Dr. Westendorp stated the issue very succinctly at the Living Well to 100 Conference held at Tufts University in 2005 when he asked, "How do we optimize an increasingly aging populations' health such that we don't simply spend more years in misery before we die?" [5] This question has been the preoccupation of many nations who have implemented policies to promote healthy aging.[6]
While there is some dispute about the definition of successful or healthy aging[7,8], Hansen-Kyle suggested that: "Healthy aging is the process of slowing down, physically and cognitively, while resiliently adapting and compensating in order to optimally function and participate in all areas of one's life (physical, cognitive, social, and spiritual)."[9] This definition has many of the elements identified in a recent review on the behavioural determinants of healthy aging by Peel et al[6] including physical activity, smoking status, diet, obesity and alcohol consumption which, with the exception of obesity, are factors targeted by the eChat tool. In addition to they important risk factors, I believe a key issue will be assessing drug abuse - whether it is illicit or not. Polypharmacy or inappropriate medication use receives a great deal of attention for the elderly but the topic of screening for substance abuse is often neglected.[10,11] Within the next two decades, baby boomers will become the largest group of elderly in North America and this same group has the highest rates of substance abuse among any previous generation.[12] In addition to increasing the number of aging early-onset drug abusers, Patterson et all speculated that the baby boomers may also result in greater numbers of individuals who develop late-onset drug or alcohol problems.[12] What I found to be one of the more interesting points made by Goodyear-Smtih in the article was that there were very few objections to the screening questions contained in the eChat tool despite asking about senstive or difficult areas such as drug and alcohol abuse.
With the burden of multimorbidity, screening for lifestyle modification in the elderly are often ignored in favour of medical interventions that may be less relevant or appropriate with increasing age. Although no statistics are provided on the average age of the two practices where Goodyear-Smith et al investigated the use of the eChat tool in New Zealand, one would assume that it would resemble most primary care practices with a higher proportion of elderly and complex patients. The interesting question then becomes whether this innovation can improve models of care for elderly and/or complex patients. As noted by the authors, the next step will be randomized trials to determine if the eChat tool can improve health outcomes and provide patient-prioritized care. Given the promising results so far, the eChat shows potential to support delivery of high quality primary care without significantly increasing costs or burdening an already overburdened healthcare system. It is interesting to consider how this tool might help health professionals cope with the changing demographic and epidemiological characteristics of our population in the delivery of primary care. I look forward to seeing the next steps of the evaluation and hope there is a focus on the role of the eChat tool to support aging well.
References:
1. Agborsangaya CB, Lau D, Lahtinen M, et al. Multimorbidity prevalence and patterns across socioeconomic determinants: a cross- sectional survey. BMC Public Health 2012;12:201.
2. Fortin M, Hudon C, Haggerty J, et al. Prevalence estimates of multimorbidity: a comparative study of two sources. BMC Health Serv Res 2010;10:111.
3. Fortin M. Prevalence of Multimorbidity Among Adults Seen in Family Practice. The Annals of Family Medicine 2005;3:223-228.
4. Wolff JL, Starfield B, Anderson G. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Intern Med 2002;162:2269-2276.
5. Westendorp RGJ. What is healthy aging in the 21st century? Am J Clin Nutr 2006;83:404S-409S.
6. Peel NM, McClure RJ, Bartlett HP. Behavioral determinants of healthy aging. Am J Prev Med 2005;28:298-304.
7. Depp CA, Jeste DV. Definitions and predictors of successful aging: a comprehensive review of larger quantitative studies. Am J Geriatr Psychiatry 2006;14:6-20.
8. McLaughlin SJ, Jette AM, Connell CM. An examination of healthy aging across a conceptual continuum: prevalence estimates, demographic patterns, and validity. J Gerontol A Biol Sci Med Sci 2012;67:783-789.
9. Hansen-Kyle L. A concept analysis of healthy aging. Nurs Forum 2005;40:45-57.
10. Jinks M, Raschko R. A profile of alcohol and prescription drug abuse in a high-risk community-based elderly population. 1990.
11. Bartlett G, Abrahamowicz M, Tamblyn R, et al. Longitudinal patterns of new Benzodiazepine use in the elderly. Pharmacoepidemiol Drug Saf 2004;13:669-682.
12. Patterson TL, Jeste DV. The Potential Impact of the Baby-Boom Generation on Substance Abuse Among Elderly Persons. Psychiatric Services 1999;50:1184-1188.
Competing interests: None declared
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Competing Interests: None declared.