Electronic Integration

IN THIS ISSUE: Rationale for Proactive C-L Psychiatry | New SIG | Electronic Integration | Telepsychiatry

Electronic Integration Leads to More Focused Discussion on Key Needs of Individual Patients

Care has become “more efficient, satisfactory, and cost-effective”

A team at Mayo Clinic set about streamlining a screening tool for depression and anxiety disorders by integrating the tool used in pre-appointment assessments with an electronic platform. They say it has enabled them to improve collection and use of data “leading to more focused discussions about the most important issues for each patient.” Care delivery, as a result, has become “more efficient, satisfactory, and cost-effective.”

They describe their three-phase implementation of the International Consortium for Health Outcomes Measurement (ICHOM) Depression and Anxiety Standard Set in a paper in the January/February edition of Psychosomatics.

Using the standards may not be feasible in all settings, they admit. But, “hopefully, with standardized tools such as the condition-specific ICHOM standards set and PROMIS (Patient-Reported Outcomes Measurement Information System) using a computerized adaptive testing approach, we will see further practices pursuing this.”

The team’s approach

  • During a preintervention phase, the team from the Department of Psychiatry and Psychology at Mayo Clinic reviewed patient-reported outcome tools, selected the ICHOM set for implementation, and engaged stakeholders and leadership to do so.
  • During phase one, the standard set was converted into an electronic pre-visit intake assessment that was implemented in a physician champion’s practice. Patients completed the intake on a tablet, and computer adaptive testing was used to reduce response burden. Physician-facing data display facilitated use during in-person visits at the point of care. An electronic version of the follow-up standard set was used during follow-up visits.
  • During phase two, a second physician tested scalability.
  • The intervention was disseminated department-wide in phase three.

The outcomes

During phase one, 186 intakes and 67 follow-up electronic patient-reported outcome sets were completed. The average patient age was 54 years, and 44% were male. On average, patients ranked the tool 4.4 out of 5 and spent 22 minutes completing the intake. Time-driven activity-based costing found the new process to be cost-effective.

During phase two, 386 patients completed electronic patient-reported outcome sets, with 315 follow-up visits. Patients ranked the tool as 4.0 out of 5 and spent 26 minutes completing the questions. During phase 3, 2,166 patients completed intake electronic patient-reported outcome sets and 1,249 follow-up visits. Patients ranked the tool 4.3 out of 5 and on average spent 26 minutes on it. Scores and completion time did not differ greatly between phases.


“It is critical to note that answers to questions do not, and cannot, replace the face-to-face clinical interview.”


Background considerations

“Health care systems are focusing on achieving and documenting better value, defined as better patient outcomes relative to the total cost,” say the team. “This is imperative, but a major barrier to doing so is the burden of collecting and assessing patient outcomes as part of a routine care delivery.

“One way to assess health care quality is by using patient-reported information. Patient-reported information about health or functional status, medical history, or social and economic indicators is often needed before a care visit to help providers assess the patient’s condition and obtain baseline measures to be compared to post-treatment outcomes.”

The team refer to these assessments, whether before or after the care sequence, as patient-reported outcomes (PROs).

“There are a number of challenges to using PROs consistently in practice,” they say. “Physicians are already spending an enormous amount of time on non-clinical activities, and burnout rates remain high. Requiring physicians to collect, review, and follow up on PROs adds to their already high workload. Furthermore, patients may consider responding to long or complex questionnaires burdensome and confusing and be upset if their responses are not directly addressed by their doctor.

“Selecting which PRO measures to use, when and how to administer them, and how to integrate them in delivering high-value care remains an area of ongoing research. We describe a three-phase electronic PRO implementation process that addresses these challenges.”

Before this project, all patients seen in the team’s C-L Psychiatry practice completed a detailed, paper-based pre-appointment questionnaire that contained demographic information, a psychiatric review of systems, assessment of depression and anxiety, past psychiatric treatment, and family and social history. Patient itineraries included 30 minutes to complete the questionnaire before appointments. Completed forms were turned in to the desk staff and made available for physicians to review during the appointment.

After the visit, physicians manually entered the information into the electronic medical record (EMR) or dictated the information as part of their consultation note. Forms were subsequently deposited in a centrally located bin, and staff from Health Information Management Services scanned and saved them as separate PDF documents in the EMR. No follow-up nor return visit information was collected.

There were several problems with this process:

  • Printing intake packets for patients scheduled for the next day resulted in considerable waste of resources and effort if a patient missed or rescheduled their appointment.
  • When completing questionnaires, patients would often provide incomplete information or check multiple responses for one item in a scale, rendering the score invalid.
  • Some patients were overwhelmed with the long questionnaires or expressed frustration at having to answer questions that did not pertain to them.
  • Physicians had to manually input information into the EMR and were not able to effectively use responses during the appointment because of difficulty in reading and scoring paper-based surveys beforehand.
  • During follow-up visits, physicians found it time-consuming to search separate scanned documents for previous responses.
  • Extracting data from the scanned forms for administrative, quality-improvement, or research purposes was challenging because of the need to recalculate or update scores as well as search through large quantities of image-based files.

“Our primary aim was to fully incorporate a standardized set of PROs in our outpatient C-L Psychiatry practice,” say the team. “Secondary aims included improving efficiency of PRO collection workflows using an electronic platform and achieving patient and physician satisfaction with the collection tool.”

To their knowledge, say the team, “this is the first successful implementation of the ICHOM Depression and Anxiety Standard Set. This study demonstrated that a phased implementation process was an effective strategy for working through problems, demonstrating positive impact on process flow and cost-effectiveness, and gaining consensus among stakeholders.”

But they add: “It is critical to note that answers to questions do not, and cannot, replace the face-to-face clinical interview. Instead, collected data points need to inform discussion and, in our case, having patients complete them ahead of time frees up clinicians’ time to talk about interpretation of these data points, rather than querying the person during the interview.

“As the responses to individual items on scales are displayed in a user-friendly visual interface (e.g., color-coding), the areas of significant impairment can be quickly discerned by visual scanning. This has the effect of transforming the consultation into a more conversational one.”


Shehzad Niazi, MD, FRCPC, FACLP
Shehzad Niazi, MD, FRCPC, FACLP

Psychosomatics journal cover

The full paper, Feasibility Study of Three-Phase Implementation of International Consortium for Health Outcomes Measurement Depression and Anxiety Standard Set in an Outpatient Consultation-Liaison Psychiatry Practicepresented by Shehzad Niazi, MD, FRCPC, FACLP, Department of Psychiatry and Psychology, Mayo Clinic, and colleagues, is here.


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