eCHAT for Lifestyle and Mental Health Screening in Primary Care

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

doi:10.1370/afm.1512

Article Figures & Data

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Table 1

Nonrespondents From 233 Invited Participants

Characteristic	No. (%)
Total nonrespondents	37 (15)
Declined, and reasons for declining	22 (9)
“Did not feel like it”/”Can’t be bothered”	4
Felt too sick	4
Doctor already has this information	2
Vision problems	2
No reason given	2
Not at the doctors to talk about self—coming in regarding a family member	1
Possible chickenpox infection—not wanting to touch iPad because might be infectious	1
Because of their condition	1
Too busy	1
Data utilization concerns	1
Not interested in at the moment but thinks it is a good idea	1
Did not want to discuss drug use with doctor	1
Not comfortable with information technology, iPad	1
Completed eCHAT, but time restraints prevented feedback	15 (6)

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Table 2

eCHAT Responses

			Help Question Responses

eCHAT Domains	Responses No.	Positive Score No. (%)	No	Yes, But Not Today	Yes
Smoking	196	29 (15)^a	7	12	10
Drinking	196	63 (32)^a	59	1	3
Drugs	195	6 (3)^a	3	1	4
Gambling	187	2 (1)	2	–	–
Depression	187	29 (16)^a	11	4	14
Anxiety	185	53 (29)^a	30	6	17
Abuse	184	19 (10)	16	2	1
Anger	182	20 (11)	15	2	3
Exercise	181	75 (41)	58	6	11

ASSIST = Alcohol, Smoking and Substance Involvement Screening Test; GAD-7 = Generalized Anxiety Disorder Assessment; PHQ-9 = Patient Health Questionnaire for Depression.
↵a Added tool (ASSIST, PHQ-9 or GAD-7) completed.

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Table 3

Quantitative Feedback From Patients

Question	Responses No.	Responded Yes No. (%)
Did you find the iPad easy to use?	193	188 (97)
Did you find all the questions clearly phrased and easy to understand?	195	176 (90)
Do you think that this is an appropriate thing for your family doctor to be offering?	188	175 (93)
Are there any questions you object to being asked?	192	7 (4)
Did you have any concerns about privacy with the process?	177	16 (9)

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Table 4

Thematic Analysis of Patient Feedback

Theme	Examples
What if anything did you like about the questionnaire?
Easy to use	“Easy to follow. Didn’t take very long. Very easy to use” (Patient [P]016).
	“That I can answer quickly and directly” (P056)!
	“Easy to use and understand. Not very time consuming” (P048)
Helpful for doctor and for doctor-patient relationship	“It seems quite personal, which is always good for a doctor-patient relationship” (P028).
	“Could be honest about things might not want to say to the doctor” (P087).
	“Using the iPad is not as (potentially) intimidating as talking to someone face to face regarding personal mental health/abuse” (P062).
	“Raising few issues which not necessarily discussed in normal consultation—opens the door to discussions with doctor” (P031).
Liked nature of the questions	“It asked questions about abuse. I think this is an easier way to let the doctor know if something is wrong at home. Very simple but effective” (P073).
	“It asks a lot of different questions about life” (P025).
	“Clearly aimed at identifying lifestyle issues” (P096).
Good use of waiting time	“The questions before entering doctors” (P073).
Good use of waiting time	“Feels effective to collect data while waiting” (P061).
Helps self-reflection	“Interesting. Good to have a look at self” (P109).
Is there anything you think could be improved?
Nature of the questions	“The options are slightly limiting” (P021).
	“Not sure people with problems would give truthful answers. Possible rephrase questions to be a little more subtle” (P096).
	“No grey areas. My circumstances aren’t the ‘norm’—I’m a victim of bizarre circumstances therefore needed other options apart from yes/no” (P038).
Additional questions	“Could ask a question about sexual problems/issues” (P081).
	“More questions on lifestyle, exercise, diet” (P017).
	“Could have provided an ‘other’ option to provide comments as some of the answers available weren’t suited to how I wanted to respond” (P014).
Issues about the iPad	“Fragility, could have handles” (P037).
	“Offer pen/paper multi choice” (P085).
	“Cleaning the iPad—lots of fingerprints” (P047).
Do you think this is an appropriate thing for your doctor to offer?
People may be more forth-coming on iPad	“Maybe get better feedback from questionnaire than patient telling doctor” (P029).
	“Because you don’t have to answer the questions to them directly” (P042).
	“Sometimes in certain circumstances the person may not answer the questions truthfully if asked in person” (P108).
Efficient way of doctor finding out about patient	“Because you may pick up problems/potential problems that the patient may not have brought up” (P102)!
	“It takes less work off them but gives them a good understanding of each patient” (P104).
	“Because it’s a record of your well-being/shows they actually care (P015).
	“Self-screening, prior to appointment—great idea” (P009).
Privacy and security concerns	“I don’t like the idea of the answers being on record for anyone to see, eg, insurance companies” (P078).
Privacy and security concerns	“Because it’s done online it may not be secure” (P018).
Invasive questions	“Was invasive and was not particularly comfortable doing it. Not what I came in for” (P020).

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Table 5

Number of eCHAT Domains Positive for All Participants and Those Concerned About Privacy Issues

	eCHAT Domains Positive, No. (%)

	0	1	2	3	4	5	6	Total
All participants	46 (23)	63 (32)	55 (28)	16 (8)	7 (4)	8 (4)	1 (1)	196 (100)
Concerned about privacy issues	1 (6)	6 (38)	7 (44)	2 (12)	0 (0)	0 (0)	0 (0)	16 (100)
Privacy issues blank or unsure	4 (21)	5 (33)	8 (53)	1 (7)	0 (0)	1 (7)	0 (0)	19 (100)

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Table 6

Thematic Analysis of Staff Feedback

Theme	Examples
What if anything did you like about eCHAT?
Easy to use	“It’s quite simplistic, it’s straightforward, patients are responding very well to it” (Receptionist [R]01).
Electronic integration helpful	“Very easy to upload into the [EHR]” (Family physician [FP]01).
	“No forms to fill in” (R05).
	“As opposed to a written form, is that it’s straight in the notes” (Nurse [N]01).
Valuable screening	“eCHAT system has allowed me to pick up occasionally on some aspects of a person’s behavior or illnesses which I probably wouldn’t have otherwise picked up on that day” (FP04).
	“I like the potential it has to help people to disclose symptoms that they mightn’t be able to tell me in the consultation” (FP03)
	“Patients find it easy to disclose problems on the eCHAT which they wouldn’t have necessarily have brought up” (FP02).
	“Fast, productive method of getting screening. Which helps us do a lot of our programs, and know more about the people” (N01).
Contribute positively to time with patients	“…because it cuts to the chase and it means the problem is there on the table right at the start of the consultation” (FP01).
	“It was seamless and a very efficient way of collecting information. The questions therefore are very important but the time spent was absolutely worthwhile it was a very efficient use of time” (FP02).
	“It couldn’t be more efficient, a lot of that information…if you tried to extract it yourself in the course of the consultation
	it would just blow out hideously, you couldn’t do it. And so, of course, often we don’t, and you just tend to fancy that you, you know, acquire that information or if it’s relevant you think you know it but sometimes you do and sometimes you don’t. I think it’s really plugging some really important holes and it’s going to have a real efficiency to what we’re doing in terms of…getting people’s important underlying problems to the surface sooner rather than later” (FP03).
	“In a sense creates more work, but that’s what we’re here for” (FP04).
Is there anything you think could be improved?
Concerns about insurance company access	“The insurance companies now have access to our notes…it asks ‘have you taken drugs’, and I know that the insurance companies are very interested in that, and I don’t know how selective they may be in 5 or 10 years’ time” (FP05).
Electronic notification	“An alert on the patient’s file that it has been done” (R05).
Font size	“He said he couldn’t see it very well, he had to go and get his reading glasses, so maybe a bit bigger writing, brighter” (R03)?
Provision of additional services	“Funding. Because a lot of the issues that it’s going to tap into are ones that are going to require extended mental health type consultations and in some instances referral to clinical psychologists” (FP03).

Additional Files

Tables

Supplemental Appendix

Supplemental Appendix. Patient Feedback.

Files in this Data Supplement:

Supplemental data: Appendix - PDF file, 2 pages.
The Article in Brief

eCHAT: Lifestyle and Mental Health Screening in Primary Care

Felicity Goodyear-Smith , and colleagues

Background Developed by researchers in New Zealand, the webWeb-based eCHAT (electronic Case-Finding and Help Assessment Tool) screens patients for problematic drinking, smoking and other drug use, gambling, exposure to abuse, anxiety, depression, anger control, and physical activity, and whether they want help with these issues. This study assesses the feasibility and acceptability of systematic use of eCHAT.

What This Study Found eCHAT appears to be feasible, acceptable, and easily integrated into patients' electronic medical records. In this study, the tool was self-administered on an iPad in the waiting room by 196 consecutive patients visiting 2 primary care practices. Most patients found the iPad easy to use and the questions easy to understand and appropriate. Feedback from clinical and office staff was also generally positive. Domains where patients wanted immediate help were anxiety, depression, physical activity, and smoking. No patient requested help with more than one issue during the consultation, and physicians did not report being overwhelmed by the requests.

Implications

eCHAT appears to be an acceptable tool for systematic finding of unhealthy behaviors and negative mood states in primary care. The authors suggest that the help question posed by the tool empowers patients to control the direction of their consultation, and call for future research to determine whether using eCHAT will lead to improved health outcomes.