Conversational IT for Better, Safer, Pediatric Care

AHRQ 2008 Annual Conference

Slide Presentation from the AHRQ 2008 Annual Conference

On September 9, 2008, William G. Adams, made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (1 MB).

Slide 1

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

William G. Adams, MD
Associate Professor of Pediatrics
Director of Child Health Informatics
Boston Medical Center/Boston University School of Medicine
badams@bu.edu

Slide 2

A screen shot of an article from The New England Journal of Medicine entitled "The Quality of Ambulatory Care Delivered to Children in the United States," and the header for an article from Pediatrics, Official Journal of the American Academy of Pediatrics entitled "Rethinking Well-Child Care."

Slide 3

A Critical Role for Patient-Centered Health IT

• Limits of clinician-centered Health IT.
• Pressing need to:
  • Respond to individuals.
  • Engage patients outside clinical settings.
  • Provide access to personal medical information.
  • Empower patients to be active participants in decisions and daily management.
  • Consider unique constraints for child-centered systems.

Slide 4

Conversational IT

• Speech-based
• Bidirectional
• Informative
• Adaptive
• Intelligent

Slide 5

Why Telephony?

• Conversational
• Ubiquitous
• Directed
• Scalable
• Outbound

Slide 6

Three Child-centered Conversational Systems

• TLC-Asthma.
• Healthy Eating and Activity Today (HEAT).
• Personal Health Partner (PHP).

Slide 7

• TLC-Asthma: An Integrated Information System for Child-centered Monitoring and Case Management.

Slide 8

TLC-Asthma Scripts

• Four age-specific child scripts (Grades K-1, 2-3, 4-6, 7+).
• 6 rotating modules.
• Separate scripts for parents.
• Modules:
  • Monitor and teach.
  • Alert nurse case manager.

Slide 9

TLC-Asthma Alert Summary*

The table shows the number and percentage of children and parents with asthma related issues.

• Child seriously ill.
  • Child: 23 (4%)
  • Parent: 3 (1%)
• Persistent asthma symptoms.
  • Child: 167 (31%)
  • Parent: 100 (22%)
• Missed school due to asthma.
  • Child: 21 (4%)
  • Parent: 0
• Medication change.
  • Child: 54 (10%)
  • Parent: 61(13%)
• Needs refill.
  • Child: 25 (5%)
  • Parent: 25 (5%)
• Medication knowledge deficiency.
  • Child: 66 (12%)
  • Parent: 50 (11%)
• Rx does not match symptoms.
  • Child: 34 (6%)
  • Parent: 54 (12%)
• Excessive reliever med. Use.
  • Child: 95 (18%)
  • Parent: 91 (20%)
• Persistent trigger exposure.
  • Child: 0
  • Parent: 9 (2%)
• Peak flow monitoring problem.
  • Child: 33 (6%)
  • Parent: 55 (12%)
• No action plan
  • Child: 3 (1%)
  • Parent: 3 (1%)
• Other
  • Child: 13 (2%)
  • Parent: 6 (1%)

• Note: *6 month intervention, 79 intervention families.

Slide 10

TLC-Asthma—Results

• No difference in emergency room (ER) visits, hospitalizations, or spirometry.
• 36% decrease in daytime symptom-days.
• 25% increase in symptom-free days.
• 67% fewer missed school days.
• Increased effect in heavier users.

• Note: Preliminary, unpublished findings.

Slide 11

• The Healthy Eating and Activity Today (HEAT) Program: Telephony-based Self Care for Overweight Children.

Slide 12

HEAT

• Two evidence-based programs.
  • Traffic Light Diet (TLC, Epstein et al).
  • Student Media Awareness to Reduce Television (SMART, Robinson et al).
• 9-12 yr old children in early stages of overweight (Body mass index (BMI) <5 above 95 percentile).
• Child's parent participates with child.
• Primary Care Physician (PCP) supports family's efforts.

Slide 13

Theoretical Foundation for HEAT Content

The table is divided into "Component" and "Theory/Goal."

• Greeting and positive praise or encouragement for sticking with the program.
  • Reinforcement to build adherence to the program.
• Follow-up on challenge/goal set in the previous call.
  • Contingency management, rewards.
• Educational topic related to weight management strategies.
  • Building behavioral capability.
• Assessment related to the topic of the call.
  • Self-monitoring/self-awareness.
• Challenge/goal setting related either to the previous challenge or to the topic of the day.
  • Building self-efficacy/goal setting Implementation intention.
• Summary statement/closing to wrap up what was discussed.

Slide 14

A screen shot of medical software opened to a sub-screen showing a test HEAT Progress Report. The screen includes the following:

• Healthy Eating and Activity Today (HEAT) Program Progress Report.
• Diet/Diet Recommendations.
• TV/TV Recommendations.
• Physical Activity.

Slide 15

The Personal Health Partner (PHP)

• Pre-visit conversation with parent.
• Pediatric primary care and medication safety.
• Randomized Controlled Trial (RCT) (assigned at time of call):
  • Usual Care.
  • Assessment (w/Electronic Health Record (EHR) Integration).
  • Assessment, Counseling, and Activation.

Slide 16

PHP System Architecture

The flowchart shows the PHP System:

• Parent calls (from anywhere).
• Call goes through the Network.
  • Starts at the Communication Gateway Server (Envox).
  • Routed to the Speech Recognition (ASR) and Text-to-Speech (TTS)—(Loquendo) and the vXML Application Server (Tomcat).
  • From the vXML Application Server it is routed to the vXML Script Development Software (Envox) and Database (SQL Server).
  • From the Database it is routed to the EHR (Logician).
• Received by the Clinician at the Primary Care Center.

Slide 17

Hypotheses

• PHP use will be associated with more comprehensive visits.
• PHP counseling will improve parental:
  • Knowledge
  • Behavior
  • Activation
• PHP will improve efficiency by pre-populating RHCM form in EHR.

Slide 18

PHP Study Design

The flowchart shows the PHP Study Design:

• Letter with brochure and login code mailed to all parents of 0-11 year old children with scheduled RHCM visits.
• Parent calls the Personal Health Partner (PHP) within 1 week of scheduled visit.
• Randomization.
  • Usual Care.
    • Brief Pre-Visit Assessment.
  • PHP Assessment Only.
    • Preventive Care Assessment.
    • Medication Management Assessment.
  • PHP with Counseling.
    • Preventive Care Assessment.
    • Medication Management Assessment.
    • Parent counseled based on assessment data and asked if further counseling desired by clinician.
• Assessment and counseling data transferred to child's EHR.
• EHR data reviewed and accepted by clinician.
• Family called by PHP 2 days after visit:
  • Assess results of Rx if given.
  • Re-inforce counseling advice (when done).
• Family called by RA 2-3 weeks after visit:
  • Assess content of visit.
  • Assess changes in behavior.
  • Assess medication management.
  • Patient Activation Measure (PAM) administered.
  • Rapid Estimate of Adult Literacy in Medicine (REALM) administered to 100 parents in each group.

Slide 19

PHP Assessment Samples

The table is divided into "Topic," "Trigger," and "Activation."

• Parental Smoking.
  • Caller is smoker.
    • Call local/national quit line.
• Child Development.
  • Failed screening.
    • Discuss concerns with PCP, offer EI phone number.
• Maternal Depression.
  • Positive screen (PHQ2), no current treatment.
    • Call/find parent PCP, discuss feelings with pediatrician.
• Tuberculosis (TB) Risk.
  • At risk, due for screening.
    • Remind clinician to do purified protein derivative (PPD).
• Medication Reconciliation.
  • Inactive or undocumented med in HER Med List.
    • NA (physician notified via HER).
• Medication Use.
  • On prescription meds.
    • Bring medication to visit.
  • Dosing errors.
    • Discuss dosing with clinician.
  • Asthma reliever used as controller.
    • Bring medication to visit and discuss use with clinician.

Slide 20

Demonstration

Slide 21

PHP: Year 1 Activities

• Script development (questions, triggers, counseling, activation).
• New script data model and tools.
• EHR data and user interfaces.
• Focus group planning.

Slide 22

A diagram resembling the orbiting of the planets around the sun.

• Healthcare's "Copernican Shift."
  • Healthcare is undergoing a "Copernican Shift"—with the consumer now placed at the center of the orbits of various healthcare strategies.
    • Home Prevention
      • Knowledge (Search)
      • Fitness (PHR)
      • Wellness (PHR)
    • Hospital
      • Hospital ERP (Azyxxi)
      • Full Enterprise
    • Home Chronic Care
      • Knowledge (Search)
      • Medication Therapy Management (MTM) (PHR)
      • Senior Care (Devices)
    • Clinic
      • Convenience (PHR)
      • Access (PHR)
    • Home Outpatient
      • MTM (PHR)
      • Monitoring (PHR)