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0:01
PBRN webinar on "Implementing Health Assessments in Primary Care, a How-To Guide.' I would like to briefly review the agenda for this webinar. First, I will explain how to submit a question to our presenters. Then I will introduce today's presenters, Douglas Fernald and Richard Ricciardi. Mr. Fernald and Dr. Ricciardi will then give their presentations. There will be time for question-and-answer sessions at a few key points in the presentation, and at the end of the presentation.
0:36
At the end of the webinar I will explain how to obtain CME credit for participation in this webinar. Please note that after today's webinar, a copy of the presentation slides will be e-mailed to all webinar registrants. If at any point during this webinar you have trouble hearing our presenters, please try hanging up the call and dialing back into the webinar. I will now explain how to submit a question to today's presenters. To submit a question you may use the go-to webinar control panel.
1:05
Type a question under the question section and hit "send," as shown in the screen shot on this slide. You may submit a question at any time throughout the presentation. During the Q&A sessions, as time allows, your questions will be read aloud and our presenters will respond. I am now pleased to introduce today's presenters. Douglas Fernald is a senior instructor with the Department of Family Medicine at the University of Colorado School of Medicine.
1:33
He is the director of Big Horn, a practice-based research network in Colorado. Since joining the Department of Family Medicine in 1996 he has worked extensively on large-and small-scale evaluation and research projects in high priority areas of practice improvement, including patient safety, laboratory testing processes, health information exchange, health assessment, and patient-centered medical home transformation.
1:58
Richard Ricciardi is a health scientist in the Center for Primary Care Prevention and Clinical Partnership at the Agency for Health Care Research and quality, and a pediatric and nurse practitioner. Before joining AHRQ in 2010, Dr. Ricciardi served on active duty for 30 years and had numerous positions with the Department of Defense, working as a nurse practitioner, senior leader,
2:21
and clinical scientist. His research interests include disease prevention and health promotion, human performance and fitness, and delivery in organization of primary health care. And I will now turn the presentation over to Doug Fernald. All right, thank you, if I could see the slides.. Yeah, Doug, you want me to get started. There we go. All right. Go ahead, Rick. Thanks, Doug, and thanks, Kristin, for that wonderful introduction and the opportunity to be part of this exciting webinar.
3:09
Good afternoon or good morning to all of you on the call. Really appreciate you taking the time out of your busy day to listen in and to learn more about all the work that the team from the University of Colorado and those of us at AHRQ have put into this project, which we hope will make your workflow and your implementation of health assessments easier, smoother, whether you're a novice at it or whether you're an expert.
3:39
On behalf of our director, or, actually, our new director, Dr. Rick Kronick, and AHRQ, I'd like to welcome you all to this webinar. It's been a true pleasure for me to serve as a science officer and government lead for this exciting project. I've had the wonderful opportunity to see this project and to write it up from the start, and then to see it awarded to such a distinguished team and group of scientists and health-care professionals from the University of Colorado.
4:16
Doug, you can go to the next slide, please. Particularly I would like to note the great work and thank Doug for his great work as leading this project, but more than that, the entire team. As you can see on screen, the complement of the team is an inter-professional group with both health services research experience, clinical trial experience, practice experience, public health experience, and a variety of scientific backgrounds that came into this project that enriched it, strengthened it
5:00
and provided us with a network that we could reach out to other professionals across the landscape to inform this project to strengthen it and, hopefully, to make it easier on you all to implement health assessments. Particularly, I also would like to recognize a senior health services researcher, Dr. David West, for his oversight and always wise discussions as this project moved forward. I will also serve as the moderator for this webinar, so when we get to the point where we have questions,
5:41
I will direct the questions to either Doug or myself and keep the questions moving. One thing you should know is if we run out of time and we have a lot of questions, we'll be sure that we get the answers into your hands through Kristin and making sure that we close all the loops on that. Doug, you can go ahead and move to the next one. Before we move into what you all came for, the meat and potatoes of this webinar,
6:12
I thought it would be helpful for all of you to get a perspective, since many of you have worked with AHRQ or have used our tools and are familiar with what our mission is on our new focus. So our new mission is to produce evidence to make health care safer, higher quality, more accessible, equitable and affordable, and to work with HHS and other partners to make sure that the evidence is understood and used. This is significantly different from our old mission, which was to change health care.
6:48
We are now producing evidence to team up and partner with others to facilitate changes, particularly enacting the Affordable Care Act and health services delivery. You can go to the next slide, Doug. AHRQ also has four priorities. Priority number one is to improve health care quality by accelerating implementation of patient-centered outcomes research. The Affordable Care Act created a national initiative to harness the potential of patient-centered outcomes research,
7:22
and as part of this effort, AHRQ is charged with investing and developing the patient-centered outcome research methods, training patient-centered outcome researchers, and disseminating patient-centered outcome finding. The second priority is to make health care safer, which the components of this are to prevent health-care associated infections, accelerate patient safety improvement in hospitals and in ambulatory settings,
7:50
reduce harm associated with obstetrical care, improve safety, and reduce medical liability, which we're taking a big role on, and accelerate patient safety improvements in nursing homes. Priority three is to increase accessibility by evaluating Affordable Care Act coverage expansions, and from this project we fall in this priority where under the Affordable Care Act it's directed to have an annual
8:21
wellness visit for Medicare recipients, and in this health assessment, we hope that in that annual wellness visit and the opportunity to look at the health risk appraisal or a health assessment, when you implement that that this guide will be much helpful in facilitating that. So this particular guide falls under the priority three. And our last priority is to improve health care affordability, efficiency, and cost transparency,
8:53
and AHRQ will develop and spread evidence and tools to measure and enhance the efficiency of health systems, the capacity to produce better quality and outcomes, while avoiding over utilization, and to maintain quality and outcomes with lower resource use. So at this point, that's the overview from AHRQ, how this particular project fits into our mission and how it came to be. At this point, I'm going to turn it over to Doug, who is going to drive us through the rest of the presentation.
9:29
Thank, Dr. Ricciardi. I'm going to start and say I have no financial disclosures or financial relationships to disclose, and I will not talk about any off-label drugs. But I do want to start here and say thank you to AHRQ and Dr. Ricciardi and all the staff there who have helped put this health assessment how-to guide together, and I also want to welcome everybody. Good morning and good afternoon.
10:01
I want to set the tone before I get going here with a quote that we had from a patient advisory group, and one of the patients in this group really had a really insightful message about health assessments. We spent some time talking with the High Plains Research Network's Community Advisory Council about health assessments, what they are, what their potential is, and how they could be used to help patients improve their health.
10:26
And at the end of the day this is one of the quotes that we really felt captured a lot of patient perspective around really using health assessments effectively, and we tried to mete that into our conversations here, and, when we developed the guide, tried to keep that in mind. And, really, the message was relationship first then health assessments, and the point being that for health assessments to work really well for the patient it works best if there is a
10:56
relationship with the provider who can understand something about the patient beyond just the check boxes and numbers on health assessment questionnaire and really help guide the patients in making good choices and improving their health. So I want to set the tone there. The effectives for the day are really to describe a little background on health assessments for primary care and define what we mean by health assessments,
11:20
talk a little bit about our practice observations for how to effectively implement health assessments and describe the work we did in our primary care research network practices and then talk about what patients said about what their priorities are for health assessments. And then we'll spend some time just going through quickly some of the main sections of the how-to guide, which is available on AHRQ's website if you don't already have that.
11:48
As Dr. Ricciardi said at the top of this, we will stop at a few points and invite questions, just a few minutes to answer any clarifying questions a couple of points in this presentation, and then, of course, we'll leave time at the end for, really, any questions about our how-to guide or any other aspect of the project. First, a little bit of background on what we mean by health assessments. You've probably all seen a questionnaire like this if you work in a primary care practice,
12:20
or if you've been a patient, you've probably answered a questionnaire like this, that asks a bunch of questions about health behaviors, health risks, the good things you're doing for your health, the things that might impact your health around social support, whatever it is. And I want to emphasize that health assessment is really more than just what the questions are on a piece of paper or a set of questions you might complete on a tablet or something like that.
12:47
When we talk to our patient advisory groups here in Colorado, they talked about what it meant to them and what they would like to see or hear about, as patients, a description of the health assessment, and here is what they came up with. This is the Colorado Research Network Patient Advisory Council. They said a health assessment is a set of questions answered by patients that asks about personal behaviors, risks, life-changing events, health roles and priorities, and overall health.
13:16
And then they went on to list a number of types of health assessment questions that might be asked. It included everything from familiar things lie tobacco use, physical activity or diet, but also included things like safety, sexual activity, things like that. So they had a pretty clear understanding what health assessments were. But I want to also go a little bit farther and develop what we learned as a more complete definition of health assessments,
13:47
and that health assessments really are a process to collect information from patients and then use that information to engage them in a conversation about their health and then really work on how to lead a patient to better health choices, better care, and improving health behaviors for the long term. And so, again, the point here we're trying to make is that it's a systematic process, it's not just answers to questions on a piece of paper.
14:16
Something actually has to happen with that information and has to be a conversation with patients that's informed and directed towards identifying and supporting beneficial health behaviors to improve the patient's health. And I also want to make the distinction that this goes a little bit beyond a simple screening tool or health histories, or sometimes in primary care practices we talk to, hey, we're thinking about these review of system forms that asks about all the diagnoses a patient has had
14:50
and surgeries and allergies and things like that. While those are important, it's not really what we're talking about in term of health assessment. This is more of a systematic comprehensive effort to collect and use information from patients to improve their health. And one other thing I want to emphasize is that when we went out to practices we talked about health department assessments and patients as well,
15:15
we learned that there was an expectation that we would show up with a single health assessment survey, and such a thing doesn't really exist. There are many different ways to ask questions about a patient's health, their health risks, their health behaviors, and there isn't a single health assessment out there. But there are many, and mostly they cover a lot of the same territory. I want to talk a little bit about why we would even consider doing routine health assessments in primary care,
15:48
and part of this what we learned from the literature in talking with our expert panel, but also what we learned in talking with primary care providers, their staff, administrators, you know, medical staff nurses, everybody who works in a primary care setting. And they were pretty clear that one of the main themes is to really improve care and improve the patient's overall health and wellbeing. That's the goal.
16:14
It's not, again, just about getting the answers to questions to fulfill some certification requirements. The other thing we heard is that it really enables practices, when you do routine health assessments, to systematically collect high-priority information from patients to improve their care, so, again, it's not just collecting a random set of questions. These are important questions, information we want to know about particular patients. One of the things that we heard from both patients
16:47
and providers is that health assessments are an opportunity to hear what the patient's priorities are, and that can help really refine options for what the next steps are going to be in designing a care plan or planning something you want to help patients do to improve their health. We also learned that health assessments done well can activate and inform patients about their own health, and it shows that you're interested in learning more than just what they're doing around diabetes care,
17:24
you care a lot of about different aspects of the health. And finally, there are some incentives out there, and the most obvious one that we're going to come back to a few times is the new annual wellness visit for Medicare beneficiaries that was rolled out as part of the Affordable Care Act for the Centers for Medicare and Medicaid Services. And just to point out a few incentives that we know of, obviously there's the medical annual wellness visit,
17:57
which is an incentive for Medicare beneficiaries to have an annual health risk assessment done. That's what the language of the guideline says and really is a routine systematic health assessment. There are also aspects of health assessments in the meaningful use criteria for demonstrating the meaning of electronic health records. There are aspects of health assessments in patient-centered medical home recognition,
18:26
and we've also heard about health systems that, as part of the profit sharing incentives, practices are expected to do routine health assessments. The other incentive, which we've heard really motivates the practices we talked with, and the providers and staff in those practices, that doing the health assessments routinely is helping to address clinical priorities or questions you might have about a certain set of patients.
18:53
That's really driving a lot of the initiative interest in how practices decide which health assessments they select. And then, repeatedly, we heard from both our patient advisory groups and from providers and staff we talk to that, really, health assessments help you have a better conversations with your patients, which is really the aim of what patients are looking for that you'll hear a little bit more about.
19:19
Just you'll want to point out that there are some barriers that I'm sure many of you are familiar if you're trying to do any kind of practice change or practice improvement activity. There is always the lack of time it takes do something new into a practice. There's often a lack of resources for appropriate follow up for patients, so once you've done a health assessment screening, how do you ensure that you have all the resources, training,
19:45
skills knowledge materials to do whatever follow up is needed, based on what you learn in a health assessment. This lack of knowledge and training came up, and this cartoon is an example. One practice we went to, they wanted to learn more about their adult patients who might have ADHD, and they were concerned about it because they just didn't feel like they knew enough about the instrumentation of
20:11
screening for it and what the scores meant, and then what would be the most evidence-based effective follow up to do. So there's that knowledge and training that might be lacking. But also on the part of patients, not all patients really understand how health assessment information and data are used, either in a conversation with the patient or in other ways as informing, say, a patient registry in their practice to look at their practice population.
20:38
And finally, we heard that some of the financial incentives are insufficient to support really full comprehensive routine health assessments. But at the end of the day, when we talked to practices, the big incentive here, I think, is that health assessments give practitioners and staff better information about their patients so they can really have a more informed conversation, and this quote came from a practice manager in one of our research network practices, and she said, you know,
21:17
"Don't be afraid of the information you're going to start seeing from health assessments. You'll have better insights and probably learn more about your patients, thus building a far better relationship with your patient than you may have thought possible." And that's pretty much what the patient said too. So there's good agreement there on one of the benefits of doing routine health assessments.
21:37
I'm going to take a little break here and let the audience ask us questions if they have any clarifying questions or observations they want us to comment on about what we're talking about in terms of health assessments for primary care. Doug, while they're writing, I will comment on an earlier question that came up. Someone mentioned that they didn't notice if there were any nurses on the University of Colorado team. I will speak first and then give Doug the opportunity.
22:16
As you all know that I'm a nurse, I'm a nurse practitioner, and I can assure you that I had a perspective that added to the project itself from the nurse practitioner role. I also feel very strongly at AHRQ that we include the physicians assistants, nurse practitioners, and other disciplines that are engaging in the whole concept of health assessments. And, Doug, you may want to make a comment on some of the practices that you reached out to and the nurses that you engaged with. Yeah.
22:48
And others, and other disciplines. Yeah, so when we went out to -- we worked with a set of 14 primary care practices, and it was a whole range of practices from large residency practice to small solo nurse practitioner-run practices in rural eastern Colorado. And when we worked with the practices we went out and talked to and observed everybody in the practice, so in every role, front desk, nurses, the clinicians in the office, and so we were really talking with everybody,
23:25
the whole team when we talked to practices about health assessments. And we also had a nurse practitioner on our expert panel that helped guide us and provide us on their perspectives and health assessments. And we also had a nurse who was on the expert panel and addressing really a heavy focus on pediatric populations too. Thanks Doug. We have another question that you may be addressing later,
23:57
but one question is "Do you provide the patient with the summary report of what their assessment shows?" I can answer that now, and we will get into that a little bit in the implementation, but it's a great question. There were differing models in practices for how to do that and when to do that. And we certainly heard from patients that they really want a report back. They want to know what the doctor or nurse practitioner or care manager or care coordinator is thinking,
24:29
what their interpretation is of the information they just supplied on their answers to the questions, so, yes, patients do want feedback. How that actually gets done really depends on the capacity, workflows, technical skills, and clinical training of who is actually reviewing responses to the health professions. Great. Thanks Doug. The next question is, it says, "Regarding the lack of resources for appropriate follow up with patients,
25:01
how would you feel about electronic assessments in assisting with health assessments?" So the use of either electronic health records or electronic-based health assessments in facilitating for practices perhaps that don't have resources to do it in person? Yeah, I think what we heard from, again, from practices and from the literature is that the technology is not quite there. There are some tools that you can purchase that will do an inventory and assessment
25:38
and then provide direct feedback to patients and give them tools to kind of walk through the prioritization process, and those can work and they can be evidence based. But I think the key here is that the follow up really should follow the evidence for what is the appropriate follow up but also insert and include a conversation with the patient that really relies on the clinical judgment of providers who really know something about the patient and all the things that might be going on with them.
26:12
Thanks Doug. And there's a question that asked "Do we have resources for tools or examples of health assessments?" Again, I think you're going to touch that later. Yes, I'll hit on that later. But the appendices in the how-to guide offer a set of questions that we know work in primary care practices and have an evidence base behind them. But we also see links to specific population resources, so different age groups or different places you can go for more detailed health assessment questions.
26:48
Someone asked, Doug, in terms of when you mentioned routine delivery of health assessments, the question is a good one, it's "How do you define routine," or in other words what is the interval, the best interval or the best practices of an interval for delivering a health assessment? That's a great question, and I'll tell you right away that the science on the interval for doing these is incomplete. We know that you have to do it at least once,
27:20
and then at least yearly is probably the best we can offer right now for a comprehensive health assessment. We heard differing opinions from the people we talked with about what the appropriate timing is. Some practices we talked to, they do them at every preventive care visit or wellness visit, which often happens annually. Of course the annual wellness for Medicare beneficiaries is once a year. And then there are some practices we talked to that actually have a routine assessment they perform
27:54
at every patient visit. They call it a "patient agenda," and it asks a set of health assessment questions and asks what their priorities are. So differing and, I would say, you know, at least once a year. Thanks Doug. There's another question that asks, "Can a clinical pharmacist be involved in conducting health assessments regarding their potential scope of practice?" I can address that a little bit if you want. Great, why don't you take that one.
28:25
I believe, from the perspective of the delivery of the health assessment, it depends on the team and how the workflow and how the team determines how they want the health assessment to be implemented. For example, if on your team you have a clinical pharmacist and that person is engaged in health promotion and understands some of the concepts, they may be part of reviewing the responses from the patient, particularly if it's a patient that's elderly and has multiple chronic conditions.
29:02
So I think a lot of it depends on the population you're serving and what your expectations are coming out of the health assessment to improve behavior, remembering that fundamentally the ultimate goal of conducting health assessments is to improve health, to improve the patient's health or move them toward optimizing their physical and mental health in a better state. So, depending on how you get there, you might be required to use different members of the team.
29:35
I think we have time for one more, Doug. But, again, those of you who have submitted will continue on when we have our next break for questions. Let me see, I think we can move on, Doug. I'll get to some of these other questions. There seems to be a bunch of overlap. Okay great. So I'll sort through some of those if you want to go ahead and resume. All right. The next section here, I want to talk a little bit about
30:16
and highlight some of the main things we learned from our work in the field with providers and their staff, administrators in the practices that were in our project. I want to first just remind us what we were doing with this contract with AHRQ. And basically the first part of this project was to identify best practices for implementing health assessment of primary care setting. And we use a number of different methods for that.
30:54
Then we had to develop a how-to guide, and then we worked with another set of practices to field test the guide and then revise the guide based on what we learned from that. And then we had to make sure the guide is available for anyone who wants to use it, which is now housed on the AHRQ website. I want to also emphasize that this was a multi-partner effort. We had representatives from the American Academy of Family Physician National Research Network participate.
31:26
We had practices from Louisiana, Georgia, New Jersey, in that network. We also had three networks here in Colorado participate; Care Net, the High Plains Research Network and Big Horn, and these are all primary care practice research networks and include both internal medicine, family medicine, and pediatric practices. And then I also want to point out what I think are one of the most important things and most important partners in this were the Care Net Patient Advisory Council
31:57
and the High Plains Community Advisory Council. And basically these are our standing committees that advise and guide the practice-based research networks in developing research studies, coming up with new ideas, interpreting results and findings, and helping to really disseminate back out to community members, things we learn from our practice-based research network effort, so a multidisciplinary effort.
32:27
And I'm just going to highlight now just a few of the key messages that helps us think about how to organize the content of the how-to guide. First of all, the main things we learn from practices is that implementing a new health assessment is best done as a team effort, involving everyone in a practice. And for those of you who are working on practice transformation about patient-centered medical home
32:54
or try to achieve meaningful use standards for electronic health records, this is not going to be unfamiliar. It's probably something there that this is a team sport to implement health assessments. We also learned that an important feature of any new health assessment is that it really needs to align with what practice's priorities are for patient care, and there are lots of things in a practice that dictate what is a priority
33:24
and a higher priority versus a lower priority, but they seem to work best when implementing health assessments if they align with one of those priorities for patient care. Another important thing we learned from the practices is that health assessments are really tools to create a dialogue and inform the conversation between a patient and his or her provider. And I've already said that, but I'm just going to emphasize again, this is what we heard from the practices,
33:51
and we had some beautiful examples of how providers can engage the patient in conversation after they've completed a health assessment, and I'll share a couple of those with you a little bit later. And then it was pretty clear that, as we observed how the process went in practices, that patients really needed a little bit more information from providers and staff and practices about what health assessments are, how the information was reviewed, and then how private providers
34:22
and practices actually use the information. I think most of the patients we spoke with were a little bit skeptical that the information just goes into a black hole like all the other pieces of paper that they have to fill out in their lives. And so practices were pretty clear that they tried to work at telling patients how they were going to use the information. We also learned that practices wanted help with a few key things in implementing health assessments,
34:53
and one of them, somebody already asked about, was, you know, help me find the questions that are suitable for primary care settings. What is that set of questions I should be asking and which are the right questions to be asking. And although there isn't a single set of questions that's ideal, they're starting to become a narrowing set kind of what I would consider kind of a starter set of health assessment questions that are fairly comprehensive.
35:18
We also heard that this annual wellness visit from Medicare takes a little bit of reorientation of patients, and practices were looking for advice and guidance on what to tell patients about this new annual wellness visit, which really talks strictly about the health assessments, versus what they might be used to during an annual physical examine. So they wanted help with that. And, again, the third bullet, for anybody who has worked on meaningful use or quality improvement activities
35:49
or registries, they're really looking for integrated health assessments with information assistance, particularly electronic health records, and then lastly, practices were pretty clear that they would like ideas, thoughts, techniques, tools for engaging patients in prioritizing care options so they're having a more efficient conversations with patients and coming to agreement about what's possible for helping engage patients in changing or improving their health.
36:22
So I want to now just share a few things that we learned from patients and community members that we talked with on our two advisory councils. And I have to say this is one of the most gratifying portions of the project, because we spend a couple of days with these advisory councils and really talked at length about what health assessments are, how they could potentially be used, and what patients really expect from them.
36:48
And as I said at the top of this, it's really all about the relationship first and health assessments. And the patients and community members went on to say that health assessments really work more effectively when they're done in context of an established relationship with their providers. And the second bullet here, if you walk away with nothing else -- this might be one of the most important bullets -- is that patients expect some
37:15
acknowledge that a health assessment questions have actually been reviewed and their responses considered. They want to know that this information isn't just being sent into a pile somewhere. They want to know somebody is taking that action on it, even if it's a very brief acknowledgement. That's what they're really looking for. And the third bullet here, it fits right in with what we've been talking about
37:38
and what we heard from practices is that health assessments should inform the conversation with their provider, so there's agreement there. And then finally, this last bullet, there's also agreement, patients want to be asked about their own health priorities as part of their health assessment. So you can ask me all you want about all these other health risk behaviors, whatever, but give me a place that I can actually say what I'm interested in and what I think is my biggest concern for the day.
38:05
And we know there are some tools and techniques out there that can actually use this information to build a more efficient office visit. I just want to pause there and see if anybody has any questions about what we learned from the work we did in serving practices for the lit review and talking with our patient advisory groups. Okay, Doug, the first question -- we'll take at least another ten minutes here -- is from someone asking "Do you think that SBIRT should be included in this approach?"
38:41
I can answer this one, Doug, because I'm familiar with the SBIRT. That's typically an approach that's used in the mental health world or behavioral health world. And I believe some of the questions that are taken out of that assessment might be directly incorporated in a health assessment. But health assessments are comprehensive across the medical landscape, looking at function and cognitive status and health-related behaviors.
39:15
So part of that is mental and behavioral health, so some of those questions are included in the health assessment. Doug, I don't know if you want to respond on any of the behavioral health questions in the health assessment. Yeah, basically I would have the same response; that the SBIRT questions certainly fit into what could be a more comprehensive health assessment, and a lot it is going to depend, too, on what the clinical priorities are for a particular practice.
39:47
If they really want to get into more health behavior, health behavior change, and mental health side of things, then it may be perfectly appropriate to include the SBIRT as one of your health assessment tools. The next is a question that we've discussed. It's a good one, and she's asking if you could talk about the advantages and drawbacks of having clinic staff ask patients health assessment questions versus patients filling them out themselves.
40:19
In addition, in your experience what is the feasibility of having patients fill out these health assessments on a patient portal prior to the visit, and, to your knowledge, are any primary care clinics in the country doing a portal or entry to the health assessment through an electronic portal? Okay, I'll take the portal question first here, and then I'll work back to the other one. We didn't, in our work, encounter any examples where patients were going into an electronic medical record portal
40:52
to answer health assessment questions, but I will tell you this, that our patients -- one of our patient advisory councils asked for that very feature. They told us, "You know, we're already on the portal checking our lab test results and checking appointments, why can't I just answer my health assessment questions right there? I could spend more time on it and I could really answer them more completely." So it's out there.
41:17
And I know we have some practices locally that are thinking about turning on that feature, but they're not quite there yet. And then the other question about whether it's better to ask patients directly the questions or let them answer it by themselves on, say, a paper questionnaire or even through a portal. We have examples of both at work. And I think a lot of it has to do with the comfort level and training that team members have in the clinic
41:45
and what they're doing, and the other aspect of it is how do we want this to fit into our workflow. And we also have examples of practices that use a kiosk type approach, where they fill out, patients fill out a health assessment questionnaire there, and then the next step is to -- the person at the front desk reviews it, or an MA reviews it, and sort of summarizes for the providers next possible action steps.
42:14
But we really saw it all, and I think it has to do with training and the workflow in an office, and the technical capabilities of an electronic system. Great. Thanks Doug. I am aware that Dr. Alex Krist out of in Richmond, in the Commonwealth of Virginia,
42:43
I think it's experimental at this point, and it hasn't been pull fully incorporated into the electronic health record, 0:42:49.000,1193:02:47.295 is doing a fair amount of work looking at portals and having some patients in that particular health-care system generate a portal entry. but that's where he wants it to go. So that's a great idea and a good point. We got a comment from someone who said they're in agreement with this,
43:02
and also excited about the fact that the Affordable Care Act is giving us the opportunity to get engaged and get more involved with health assessments. And I guess I would say that Doug and I both agree with that, and appreciate that response. Let's see, I'll move down the list here. One question about, "Did you find in clinical practice that there was disparities between the questions and recommendations from the U.S. Preventative Services Task Force
43:41
And the common questions that are used to generate answers on health assessment form, or are they generally in alignment?" So they're generally in alignment. And the thing about the U. S. Preventative Services Task Force recommendation is they often don't specify which particular questions you should ask. Just to use depression screening as an example, the depression screening questions that we found in moat health assessments, most people are using PHQ-2 or the PHQ-9,
44:20
which really aligns nicely with the recommendations from the Preventive Services Task Force. I will say, though, that the key here is that the recommendation is that you only do the screening if you have the appropriate resources available for follow up. And I think that's the message we hear loud and clear for all these questions, is the questions are only half of it. The rest of it is really how you follow up with this those questions, including maybe more in-depth screening
44:52
or evaluation tools. Thanks Doug. The next is a good question, where someone is asking, "Will you describe use of aggregate data compiled from health assessments; for example, identifying frequent patient concerns, risk stratification, or risk modeling of patient population." So, essentially the use of health assessment data to inform your population. Is that something that you've encountered or would recommend is basically the question? Yeah.
45:31
And part of what's in the later sections of the guide is this idea of thinking about your patient population or a population health in, say, a community, and we did hear from practices that especially for patients with chronic illnesses, that the health assessments actually helped their care managers understand where they can get some traction in terms of having a good conversation with patients and how they can engage them in identifying one
46:00
or two things a patient can work on to, you know, help manage a chronic condition like diabetes. So, yeah, there's absolutely potential and good potential for using health assessment questions at both a practice level and understanding the dimensions of your patients on different health assessment parameters, and also at a population level if you're working within a larger system or in a community.
46:24
The next question is someone who is validating what we're saying about the value of health assessments; however, is somewhat concerned about incentivizing their use; for example, are there strategies to assist clinicians in seeing the value of implementing a health assessment? So there are two ways to think about this. One is just the straight ahead financial incentives. One practice we worked with, what made this a priority for them was they had a relatively large Medicare population,
47:03
and this was low-hanging fruit for them. They had to implement some kind of comprehensive routine health assessment to access those dollars that were made available through their Medicare beneficiaries, so they wanted to do that. The other way to think about it is that when we talk to practices, every clinician we talked to, every manager we talked to, even folks at front desk, they all have lots of questions and want to know more about their patients.
47:33
And so the value and the incentive is how can I do this? How can I help construct health assessments in a way that gives me clinical information that I need to take care of my patients, and that was the bigger incentive for why practices do this or think about doing this initially. It really is driven by a clinical need. And thinking more broadly, I'll use the ADHD example again, this one practice we talked to,
48:03
the reason they were adding adult ADHD to their routine screening was they wanted to get a picture of what's the prevalence in our practice today. I have no idea, and if it's really high, then I need to get more training and understand more about this. So there are both clinical incentives to improve the care of patients, and there are some financial incentives. And understanding this, that there are barriers and challenges in changes practices,
48:41
that this particular guide provides valuable tools that can assess the practice to see the readiness and what are some of the gaps, and then perhaps work on what the areas that the commissions may not see value to facilitate and narrow some of those gaps. So there's a lot of tools in this guide that can help move the health assessment implementation forward. Someone is asking, "What are the cardinal constructs covered within a health assessment?"
49:11
So what are the fundamental or underpinnings that are part of the health assessment in terms of the conceptual areas? If I understand what is being asked about cardinal constructs, they're going to include a lot of familiar health risks and beneficial health behaviors, so it includes, I would say the guidelines from CMS on the annual health risk assessment is a pretty good list but includes things like alcohol use, anxiety, cognitive impairment, depression, physical activity and diet,
49:54
overall health and wellbeing or quality of life, safety, that's a big one, social support or isolation, stress, substance abuse, alcohol use, and tobacco use. And I guess that's my short list of the cardinal constructs. There's a list in the how-to guide in Appendix 8 that I think lists most of the common ones that we heard about. And, you know, that's something that we struggle with, because it depends on the population that you're serving.
50:28
Obviously if you're a pediatric practice your health assessment will engage both parents or caretakers, as well as the patients, and they'll have to have a developmental perspective to it. If you have a adolescent practice it will be different, and then you're dealing with young adults. The health risks associated with young adults are different than the health risks associated with a Medicare population. So that's a great question. It's one we struggled with.
50:59
And we hope that the guide will provide ample evidence across the lifespan to provide some constructs or some validated questions to facilitate implementation in the practice that you're serving. So that's a very good question. "Could you differentiate between" -- we'll take a couple more questions -- "between health assessment and health risk assessment? The annual wellness visit requires the latter, so the difference between health assessment
51:28
and health risk assessment or health risk appraisal?" I'll take a crack at that. But in my mind, health assessment is a little broader because you might also be assessing beneficial behaviors, not just risk. So you want to encourage the things patient is doing well versus just identifying risk. Otherwise, I think, as the previous question asked, the cardinal constructs are basically the same.
51:56
I think the health assessment is just a little broader in how we think about getting beyond just identifying risk but also identifying beneficial behaviors to encourage in patients. All right, thanks, Doug. I think we'll stop here on questions. Again, we'll have a little more time at the end of the session to answer the rest of the questions, so I'm going to turn it back to you, Doug. Okay great.
52:23
In this last section I basically just want to walk through how we put the guide together, what informed it, and then spend just a little bit of time on each section of the guide and just highlight what's in that section. And then at the end, we'll take any questions about the how-to guide itself or any other questions that we didn't get to about health assessments. So when we assembled the how-to guide, as I said,
52:50
we did some in-practice observations in a set primary care practices, all different sizes and types, and really took a close look and evaluated how practices were implementing health assessments. And we looked at practices that use both electronic data collection tools and paper-based tools, and then we developed the guide and actually took it back to actually eight more practices and did a field test,
53:24
and basically said here's a guide on how to implement health assessments, go forth and do whatever you choose to do. We didn't give them a lot of guidance on which particular questions to ask or what to focus on. We really wanted them to work their way through the guide on their own and let us learn and observe. We also spent some time on in-depth interviews with providers and staff about what challenges are around implementing health assessments effectively.
53:53
We did a review of the literature, looking specifically for best practices, and also looking at implementation using electronic systems, which the data were sparse on best practices, and that article just came out in the Journal of Ambulatory Care Management, so that's out there. And then we also had our patient advisory groups weigh in, and expert panelists weigh in,
54:20
and then we did a final clinical review of the how-to guide's content and recommendations in there. 0:54:21.000,1193:02:47.295 and really guide us in asking and probing certain areas of health assessment implementation, I just want to say a little bit about who this guide is intended for and why we thought about it this way. It really is intended for any primary care practice that wants to implement any health assessment.
54:41
, if it's aimed and seniors, adults, children or adolescents, it doesn't really matter. The guide is really aimed at walking through the steps in helping a practice think about what might be involved in selecting and implementing, and evaluating over time how they would implement to help assessments. It's designed to be used by providers and staff who really want to improve the conversation with their patients,
55:03
so whatever information is going to help do that and a process that's going to help do that, this guide aims to inform that. It's designed for clinical leaders, managerial leaders, quality improvement organizations, anybody who wants a little more guidance or a set of reminders about what to think about when implementing health assessments. And part of how we designed the content was really to optimize this for use in a practice team.
55:34
And Dr. Ricciardi mentioned this, and we heard from practices about how to do this well, and we know that it really requires a team to implement this and think about the implementation. It doesn't all have to fall on the shoulders of a provider to ask and review assessments or figure out how to do all the implementation. It works best in teams, and so that's how we decide the guide. And then also some tools in here to help patients engage in that conversation about whatever information
56:07
is on the health assessment and how that fits in with what the providers know are the important things to address for the patient. So that's kind of how we oriented the sections and the content of the sections. So basically what's in the guide is step-by-step guidance. We broke it into six what we call "decision points" for implementation. It includes practical lessons that we learned from others who have done this.
56:34
There are some tools and checklists throughout the guide, and in the appendices there are more tools, including health assessment questions and links to other resources, such as coding for preventative care that might be related to health assessments, and then a lot of additional resources around practice improvement processing for working on the workload, things like that. As I said, this guide is really organized into six decision points.
57:09
This is a piece of feedback from one of our expert panelists who said, "You know, when I think about this, I think of these are the questions I want to be asking myself as a provider, but also the people I work with in my practice, and so that's how we organize it, it's in these decision points". So the first one is around practice readiness, just a quick inventory of how ready a practice might be ready to embark on implementing a health assessment of any kind.
57:37
The second section talks about planning tools and reviewing priorities for selecting which assessment you want to implement. Section three is the longer section. It's all about implementing this and integrating this into workflows. Section four talks about how to use the information, so, again, it's not just about collecting the data, it also has to be put to use. And section five we thought was important, about including patients or involving patients in this conversation
58:11
and how to do that in a way that engages and activates the patient to take action. And then a little bit about sustaining health assessments, and, really, that requires some evaluation over time about is it still meeting your needs, is there a little bit of remedy coming in from this, what are all the things you might want to think about to sustain to help assessment over time. So if you have the guide in front of you or opened up online somewhere,
58:40
I'm just going to take a quick snapshot of each of the sections and, again, leave it open for questions after this. Section one, as I said, is readiness assessment. It's just a quick checklist just to get you thinking about the whole process from top to bottom. And one of the ways we heard a practice think about this is the provider told us that, "You know, I do a lot of quality improvement work and how this has helped me is,
59:08
it's just reminded me of all the things I need to think about before I embark on any practice change, including implementing new health assessment." And so this checklist is designed to just walk through some things to think about and then where in the guide you might find guidance for tools to help answer the questions. The next section is about choosing an assessment, and, again, we asked a few more questions here about, you know,
59:39
is there a particular population you want to focus on that is a priority for you right now in your practice and some other questions, and then we provide a crosswalk, and this is really designed to help you think about things you might already be doing and ways you might already be collecting some health assessment information, and so you're aligning health assessment with other improvement programs or whatever you have to do for further recognition or incentives.
1:00:09
Section three is, again, the biggest section about how do you get this into your office workflow. So you figured out what you want to do, it's a priority for the practice, how do you get the health assessment into the workflow? And, again, I just want to emphasize that it's a team effort. We know that works well. All the burden doesn't have to fall on physicians or nurse practitioners or any provider in the practice.
1:00:36
There are lots of ways to think about using a team, so lots of examples of how a team member can review and sort of prep the information and hand it to a provider, or they can enter the data into an electronic system that then prompts the provider later, so lots of ways to think about using your team. And this is also a little bit -- we offer a number of different sets of questions, really, to think about some the implementation details.
1:01:05
Who is actually going to identify which patients to get this, how will that be done? Where is the information going to go? Is it going to stay on a paper form and be handed off to a provider or a care manager, or does it need to go into an electronic health record or other data system? So we just set up a lot of questions just as reminders to think about for really getting the implementation and integration down. Section four really hits on a question of, you know,
1:01:39
now that we have this information from our patients what are we going to do with it? And it mostly emphasizes really meeting patient expectations and talking to patients about how the information is going to be used. And I'll just share with you a great example we heard from in one practice we we're working with, and their method for engaging patients and acknowledging to patients
1:02:05
that this was important is they decided they need to screen -- as part of meeting their incentive program requirement, they needed to have a certain set of questions that every patient with diabetes was asked, so they had to implement that. And their strategy was to hand the MA and the paper form to the patient when they checked in and then instructed the patient to hand that piece of paper to the provider when the provider walked in.
1:02:33
And then when the medical assistant was done and the provider came into the exam room, the provider would either ask for the piece of paper or the patient would offer it, and right then and there the provider would do a quick scan and look for two things, one was encouraging things like, "Oh, I see you're doing great on your physical activity this month, keep it up," and then one thing to tie into a chronic condition or a worry the patient had about, say, heart disease or diabetes.
1:03:07
And so it was an instantaneous transaction there, but it really forced the message to a patient that, yeah, this is important. Not only is the MA looking at this but also my provider, my doctor is looking at this, and that seemed to work very well. And that's just a sort of an example there of how that might work in a practice. And that fits in with section five, which is really how you engage or activate patients to use the information.
1:03:34
And, again, it's all about reinforcing to the patient that the information is important and what you're doing as either a provider or as a practice to help the patient prioritize and make decisions about what would really help and be beneficial to their health. And then the last section is really about sustaining a health assessment, so once this thing is up and running, how do you keep it going?
1:04:02
Are there particular incentives this continues to align with so you have a little bit of revenue coming in from this, and, importantly, is it still meeting you clinical priorities? Are the questions we're asking, are they hitting the mark? Are patients answering them in a way that we can doing so with the information usefully? And are we able to give the feedback and follow up we need on these questions, or do we need to change something?
1:04:26
And we heard from practices, and one practice said, you know, It's best to get patient input directly, and so they learned from patient surveys. And one practice said, "You know, really should just have a patient focus group around this. We learned a lot of information from convening our patients around a particular question that we have in our practice." So different ways to do that.
1:04:47
But, again, it's just about evaluating as you go, is this health assessment still meeting a need for us in our clinic, and are we able to implement it as effectively as we had hoped? I just want to point to the last bit here is the appendices. Throughout the guide there are links to resources in the appendices, which this example includes a sample script for the annual wellness visit, but there are a lot more resources in there with directions
1:05:19
or links to websites for more detailed information around coding, more particular health assessments for specific populations, and even some tools that you can use directly with patients. And we also, in response to what we heard from practices, provide at least a starter set of health assessment questions that have evidence and means suitable for primary care practices. And here is a good link for AHRQ's Health Information Technology website, which has some great workflow tools for,
1:05:58
in this case, information technology, but all the same tools apply for implementing health assessment tools, so that's a great resource. Just a few takeaways before I open it up for questions, patients basically want what we want. They want to have an informed conversation. Health assessments can help do that. Patients also want to talk with their providers about health assessments, and they're certainly expecting it.
1:06:25
Team work works, and do this in small steps, and then organize the effort around a practice priority and it's more likely to be a successful longer-term sustainable implementation of the health assessment. I'll just open it up for questions now. Thanks, Doug, great presentation, and I look forward to having you address some of these questions. We have quite a few of them, so I will just start from the top here.
1:06:56
The first question is, "How well do the health assessments fit into discrete data in electronic health records? Also, the second part of this is, "Can the data acquired from health assessments be used in population management, as well as with the respective to the individual patient?" Great question, and a lot depends on the electronic health record you have and the availability of these questions being in your electronic health record already, or the ability to add them.
1:07:32
And our experience was that some EHRs are better at this than others, and some of it also depends on the sophistication of the data extraction tools you have for your EHR to be able to both enter the data into discrete fields and then extract it in a usable efficient timely way so you can actually have a conversation with the patient, either at the time of the visit or at some later point. But we did seek samples of this.
1:08:01
In fact one practice we went to was using an electronic check-in tool where they had a tablet that had a health assessment that fed directly into their EHR and then later prompted the physician around areas of concern they might want to talk with the patient about when they met them in the exam room. So, yes, that can happen in real time. And then also, that same practice was using the information they collected from the tablet health assessment for later
1:08:32
to report to their care manager for the patient's with diabetes for specific things they could follow up on with the patients if they were having trouble managing their diabetes, and it might be that having a conversation with a patient about working with them on improving their diet or physical activity or something like that. So, yes, you can use these information electronically for both an individual patient and population or practice-level needs, with different capacity for that.
1:09:03
But, yeah, certainly can be done, but a lot depends on the information systems you have. Thanks Doug. The next question is about reimbursement. This particular person is saying they have experience with submitting requests for payment to insurance companies and they're not getting reimbursed. And I guess I'll add to that. I guess what they're asking is did we see any of that or have you heard much of that in preparing this guide? So I'm no expert on the billing and coding and all that,
1:09:42
but we did hear some examples where there were a few codes that could be used pretty effectively and reliably for reimbursement. This is outside the any wellness visits for Medicare patients, but there were not many. And, again, I don't know what the rules are around billing and coding, but mostly they seem to be in the preventative care set of codes around identifying a particular specific health risk, such as one example we came across regularly was risky sexual behavior. Okay thanks Doug.
1:10:26
And as you said, the Medicare visit is fully reimbursable, but some of the private insurers may not have signed onto that or not signing on fully to that, so some of the codes that are mentioned in the guide could be helpful in trying to get some reimbursement or to maintain reimbursement. The next question deals with, similar in part, are the health assessments integrated into a specific part of the electronic health report, some of this which you addressed, and are there applicable ICD codes
1:11:03
or others that can be input based on the findings to help establish registries and retrieve data not only for quality improvement initiatives? So there are a couple of questions in there, and, again, I'm know expert on the billing and coding, but there are -- so if you're thinking about meaningful use criteria for establishing meaningful use and demonstrating meaningful use of an electronic health record, then some of the questions that are required of that,
1:11:41
for example, documenting that you ask and advise about tobacco use, those align quite well with health assessments in general, but I really can't speak to other codes or ICD-9 codes and how they align with specific health assessment questions. I will say, though, that the American College of Physicians or Internal medicine, the WAP for family physician, the ACP for pediatrics include -- on their websites they have very detailed billing and coding pocket guides
1:12:28
and more detailed guides for their membership, and we want to look at this a little more carefully. And they're very descriptive about the types of codes you can use for particular clinical activities. Thanks Doug. Next question is "How have health assessments, or how could health assessments be used with behavioral health, such as the PHQ-9 tool for screening for depression? And can these health assessments be seen as success or a barrier for implementing depression screens?"
1:13:02
That's a great question. And again, I'll share an experience in one of the practices we visited. They actually agonized quite a bit over whether they wanted to do a PHQ-2 at every visit for their patients. They thought they would be overwhelmed with the number of positive PHQ-2s that would have to be required at the full PHQ-9. They decided to do it because it was the right thing to do for their patients, and it turned out that what they landed on was a very good system,
1:13:34
was to do the first screening questions for the PHQ-2 for depression, and then of those that required follow up, then immediately do the PHQ-9 and it ended up working very well and not being burdensome, in large part, because this was something their medical assistants could do, and so the provider really didn't have to do anything and only had to act when they saw this PHQ-9 appear in their electronic health record for that patient when they met them in the exam room.
1:14:08
And over and over we saw pretty much every practice we went to was using a PHQ-2 as the initial screener for depression. It's widely accepted and it's often needed for some of the recognition programs anyway. Okay thanks Doug. The next question is another good question. "In your experience, is it important to have someone clinical to implement the health assessment or can patients do the health assessment on their own, or do you need someone to walk them through each question?"
1:14:44
So most of the practices we visited, patients do it on their own, and no problems with that. And the way it typically goes is the patient will complete it on their own, his or her own, and then a staff member will review that. And if there is missing information, the staff member will just ask them directly to fill in the information. Most of the time patients were very good about completing all the information. They're used to it and didn't have any problems.
1:15:17
There were some practices that talked about there's always a set of patients where we just need to do this one on one and help them answer the questions. And they just didn't encounter much resistance to that. So both methods work. We didn't observe -- for some specifics sets of questions there was a preference from some of the clinicians to ask the questions directly, because they felt like they could get a better answer.
1:15:43
But, for the most part, these are questions that patients can answer on their own, either at the time of visit or outside the visit and then bring in the questions or have them sent directly to the electronic medical record. Both work well, or all work well. Thanks Doug. The next question, you may have touched on most of this, but I'll bring it back up and see if you have anything to add.
1:16:10
"From a logistical perspective how was the health assessment completed; for example, was it sent to the patient? Was it completed prior to their visit, and was it sent to the provider before their visit?" I'll share a couple of examples. The two practices that were using the guide to implement the full annual wellness visit assessment, they sent them to their patients first before the visit, with a clear message that we want you to fill this out
1:16:42
and bring it to the visit you have with our provider. So I think one practice reported about 80% of their patients did actually complete the full health assessment before their visit. And then in terms of the handoff of that information to the provider, again, that varies entirely by preferences for what's going to work with the practice flow and what providers want to see and how they want to have an interaction or conversation with patients. But we saw all kinds of things that worked,
1:17:14
including handing the health assessment directly to the provider who reviews it right there and gives immediate feedback to the patients, versus the provider just scanning quickly for things of concern, or even having a medical assistant kind of preview the health assessment and flag for the provider things that were concerning, so all kinds of methods that really depends on staff capacity, workflow, training, and clinical preferences. Thanks Doug.
1:17:48
We have a comment from Lynn Gilbert, a colleague of mine, says that she wanted to bring up a focus bilingual health assessment called "Heart smart kids for evaluating cardiovascular risks," including overweight and obesity in pediatric and primary care and community surveillance. She provided the link, but it's www.heartsmartkids.com, and we'll send that out to everyone. Thanks Lynn. There is also additional information on adolescence that the University of Colorado has prepared in another time,
1:18:31
and not too long ago that we include in this health assessment guide. So it's always helpful to give additional methods on kids. Yeah. There's a really good question. I'm not sure we've touched on this, but there is a question around patient privacy and how the question should be asked and how do we maintain patient privacy around the health assessments? So of course you have to comply with all the HIPAA regulation around privacy,
1:19:14
but I will share with you what both patients and community members in our advisory groups told us is. You know, they really expect that when they fill this out anybody in a practice was going to see this, and they were not overly concerned with privacy about the information contained on the health assessments, even on the more sensitive questions. And their feeling was if the question is so sensitive I don't want to answer it then I'm not going to answer it.
1:19:42
And so I don't think there was much concern on the part of patients to do anything extraordinary about privacy. I think that's a really good question too, because as we did our review of the literature, we realize that many of the originations of the health risk appraisal comes from occupational health, and there are some individuals who still are thinking, "Oh, is my job going to get this information" or "who is going to get this information."
1:20:14
But, as Doug said, it needs to be clear to the patients that this is a health-related health assessment, and it's HIPAA compliant and all that, so the information will not be getting back to their employers, which is, you know, something that in the earliest stages of the health risk appraisal was out there. Yeah. Thank you for that reminder, Rick. The patients were clear about this point, that they were concerned about their health plans getting this information.
1:20:52
So they really expected this was confined to people in the practice seeing this information and not going outside the practice. And, you know, underscore that when you're dealing with adolescence and who is getting the information and who is going to have eyes on it. So I think the privacy issue is a good one and something that needs to be considered across the practices and how you can best handle that.
1:21:21
There is a question on how has health assessment translated into better patient outcomes, or, in terms of looking at metrics, how can we define outcomes? I don't know if you want to tackle that one, Doug. Sure. So I'll start by saying, again, the science here is incomplete on comprehensive health assessments, and if you took a global picture of how do things change over time on a comprehensive health assessment, those data aren't complete,
1:21:55
but we do know from occupational health that doing health assessments routinely can improve health outcomes on a number of different metrics, common ones around blood pressure, lipid levels, physical activity and diet, if you want to consider that, intermediate outcome. But we also know from specific questions on health assessment that when they're addressed in alignment with the evidence that you can improve the outcomes. And just as an example would be depression screening.
1:22:27
I mean the whole recommendation from the Preventative Services Task Force is that the screening actually works. If you can do the screening and appropriate follow up, you will get a benefit and you will see improved outcomes on a depression metrics. I will see that many of the metrics that we have included in the guide are sensitive to change over time and could be used to monitor things like quality of life or improvements in physical activity or nutrition. Thank Doug. Someone mentioned this.
1:23:01
I think it's kind of a comment or maybe a question about integration of health information into tablets or some form of new electronic media, when patients complete their registration for their appointment or make their appointment as a potential. Have you encountered that or seen that? Yes. And it can work, and there are a few applications out there, two of I can think of off the top of my head. I'm not going to give the commercial names of them out, but they do work on a tablet platform
1:23:40
or a TS platform at patient check-in. The patient completes the health assessment and then it feeds directly into an electronic health record, and then the electronic health record does whatever it needs to with the data, or some other third-party data extraction tool. The one system we observed, the tablet was actually a real-time look at patients as they were answering questions, and so you could see how far along in the questionnaire patients were so you kind of had an idea how soon they were
1:24:16
going to be done. It was a really neat system. So, yes, it can be done, and then those data can be used immediately at the time of visit or on the back end for more practice-level work. Thanks Doug. There's a comment from someone mentioning that there is a tool called "ePRO," Electronic Patient Reported Outcomes, that has been endorsed by the FDA and is used in clinical research. So I guess it's one of many tools that are out there when conducting clinical trials that conducts information from
1:24:49
patient reported, and he's saying that that particularly maybe a useful tool that can be brought into clinical practice to engage patients in completing health assessments. I don't know if you want to comment on that, Doug, or not. Yeah, thank you. And that just triggered in my brain something about there is movement afoot to consolidate these health assessment questions into kind of a bounded set of more common questions so that we're getting a bit more alignment so that
1:25:26
patients aren't being asked the same question ten different ways. And so there's some consolidation of these questions, which I think patient also appreciate, but it also gives us the ability to use the same question across a lot of different settings for answering bigger questions about population health, for example. Thanks Doug. The next person had a comment and a question. He states that -- he or she states that it's time consuming to do a mini mental exam at the time
1:25:57
of an annual wellness visit. In the health guide do we provide anything that evaluates cognitive function that could be used during an annual wellness visit? I believe there is -- I'm not sure if it ended up in this guide, there might be one question around that. I think there's a couple of questions that are in the guide that circle around looking at evaluating mental status, and we do give, I think, links, but I believe there's two or three questions, Doug, in the guide.
1:26:39
And just to be clear on this point, that the annual wellness visit is designed to only talk about the health risk assessment with the patient. And we heard from more than one practice, if you try to do more than that it's very difficult to do and you might not get reimbursed for it, or the patient might have to pay an extra co-pay. So just a word of caution there. Yeah thanks Doug. Here's a great question, a practical one.
1:27:13
"How can aggregate data be easily obtained within an office setting when everyone is busy seeing patients?" So great question, and, again, the way we saw it in practices is it was somebody's job to get the training, have the tools, skills, and knowledge and the technical tools and knowledge to do that behind the scenes. So it's not necessarily a provider's job to do that or a medical assistant's job, but it does take a realignment of priorities in a practice to say, okay, this is somebody's job
1:27:53
and here's how we're going to carve out time for that person to do that, because we think it's important understanding something about our patient population. So it can be done, but, again, it takes a little bit of realignment of priorities. Thanks Doug. Here is an important question. "Can you elaborate in the development of the guide on the sources for the individual questions. Are most of the questions part of an evidence based validated scale of some sort?" So the short answer is yes.
1:28:25
The longer answer is we drew from a number of different sources and including one source, which was published by the Centers for Disease Control and Prevention, that really took a closer look at the health assessment process, specifically for the annual wellness visit, and they compiled a set of questions, and most of them have a history of use,in primary care settings in particular, but also have an evidence-basis on their own. And without getting into details, yes,
1:29:00
there is evidence for a citable source for each of the questions in the guide we provide. Thanks Doug. The next question is, "Do you know of any available health assessments or health risk assessments or software available to do this kind of work?" So, again, there are a number of commercial assessment tools out there that are available, and typically they had been available to health plans and employers,
1:29:35
but they're also certainly available to primary care practices if you want to go that route. And in some cases there are modules or questions built into an electronic health record, but it can take some pretty detailed knowledge of where they are in the electronic record to extract them and make them usable. Okay, we do have about maybe six or seven questions that we didn't get to; however, we will provide answers to those via e-mail to the individuals that have asked it.
1:30:13
At this point, I would like to thank Doug and Kristin for the opportunity to provide you with this information for Doug and his team for all their great work, and I'll give Doug a minute or so to close out, if he has any parting comments. No parting comments. I'll just leave this on the last slide here, and, again, want to thank Dr. Ricciardi and all the folks at AHRQ and Associates for pulling together this webinar. It was a great. I loved the opportunity to talk to everyone.
1:30:52
And here is the web address where you can get the how-to guide. It's available for download. And if you would just go to the AHRQ homepage there's a scrolling slide show there, and the second option will take you directly to the guide. And thank you very much and have a good day. Kristin, did you need to get back on? Yeah, we'll just show a couple final slides. Thank you for that wonderful presentation, and thanks, everyone, for attending the webinar today.
1:31:19
We just wanted to let you know that this live activity, this webinar, has been approved for 1.25 elective credits from the American Academy of Family physicians. If you would like to obtain CME credit for participating, please complete the online evaluation that you'll be prompted with at the end of the webinar and then put an e-mail out at pbrn@ebtassoc,com to request a copy of your CME certificate. Please stay in touch with us by joining the PBRN listserv.
1:31:49
Listserv members receive a biweekly digest and other announcements of interest, and you can join the listserv just by sending us an e-mail. And finally, thank you again for attending. Please visit the PBRN website for more information on other webinars and events, and please feel free to e-mail us at any time with suggestions for additional webinar topics. Thank you again, and this concludes today's webinar. Great job. Thank you. 1017 01:32:16,000 Great job.
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