Self-management via digital triage in Primary Care
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- Charlene Marshall
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1 Self-management via digital triage in Primary Care Dr J van Gemert-Pijnen, Drs S Kelders Faculty of Behavioural Sciences, University of Twente; Tromso, 2008
2 Self-management via web-based communication systems, econsult Communication trough computer-based applications to receive guidance and support on a health related issue Free text consult: communication with GP in your own vocabulary Triage consult: communication via a symptom driven system, without involvement of GP (Questionnaire; computer generated self-care advice) Nijland, Van Gemert-Pijnen et al, Evaluation of Internet-Based Technology for Supporting Self-Care: Problems Encountered by Patients and Caregivers When Using Self-Care Applications, JMIR, May 2008
3 Online patient interviewing; triage ecuity Classification of patient acuity that characterizes the degree to which the patient s condition is life or limb threatening, and whether immediate treatment is needed (Gilboy et al, 2005)
4 Digital triage in Primary Care to assist patients and persons in self-management skills and healthy behaviors through fully automated diagnosis and advice (decision framework) to empower patients and to reduce unnecessary doctors visits (self-limiting diseases) when to contact a doctor ; what a doctor can do, what you can do.
5 The digital (fully automated) triage consult ISO standards; certified TNO-QMIC (quality standards) and NHG (national standards primary care) encrypted software for secure exchange of information free service from insurance companies 25 entry complaints (self-limiting diseases, based on ICPC each complaint leads to specific triage modules high frequency complaints possibility to rule out emergencies covers 35% of primary care visits (Verlinden, 2005)
6 Focus of our study The contribution of digital triage to self-management what kind of complaints were submitted? what kind of advice was generated by the digital triage system? (retrospective analysis from one year, yielding inquiries ) The compliance with a fully automated advice which factors influence the intention to comply with computer generated advice? which factors influence actual compliance; non-compliance? (online surveys among current users)
7 Consultation process, a) Identifying the complaint log-on with a user-id password identify your complaint on the virtual body (a click on the body) cough
8 Consultation process: b) gathering personal information via a symptom driven question-answer system; varying according to gender, age, answers to previous questions How goes your coughing? I cough sometimes I cough often I cough in fits
9 Content of advice contact a doctor contact a doctor in case of emergency (as soon as possible, in short time, in 24 hours) tailored self-care advice diagnose and advice tailored to a complaint the cause of your complaint what a doctor can do; what you can do the source of the medical advice (evidence)
10 Example of self-care advice although your complaints can be (very) irritating, there are no reasons to worry you have a common disease, you do not need to visit your GP your complaints indicate an upper airway disease, caused by a virus or a bacteria this is a non-severe disease, which recovers spontaneously within 1 to 2 weeks what a doctor can do, what you can do
11 Process of submitting complaints and receiving advice Process of submitting complaints and receiving advice 29% of started consults received advice
12 Frequency of complaints (n=6538) Itch on the head 1.3 (83) swollen legs 1.3 (83) Complaint-entry knee complaints ankle complaints forgotten contraceptive 1.3 (86) 1.5 (96) 2.1 (140) foot complaints 2.6 (168) ear complaints 2.7 (174) eye complaints 2.8 (182) bitten by human or animal 3.1 (202) itch in armpit/pubic hair 4.3 (284) shoulder complaints 4.5 (297) lower backpain headache 7.5 (493) 8.0 (522) > 70 % of complaints diarrhoea 10.2 (669) urinary complaints 11.7 (763) itch, red spots and/or bumps 13.2 (861) cough, running nose, throat pain 21.9 (1435) % en (n) respondents
13 100 Frequency of advice (n=3812) Total n = 3812 % and (n) respondents (1914) (561) 16.8 (642) 15.0 (570) (125) GP - urgent GP- soon GP- short term GP- 24 hrs Selfcare type of advice received
14 Generated advice related to frequent/infrequent complaints complaints Contact a doctor in % tailored self-care in % urgent (112) soon shortterm 24hrs advice (and diagnose) cough n= =100% itch, red spots and/or bumps n= urinary complaints n= diarrhoea n= headache n= eye complaints n= ear complaints n= foot complaints n= forgotten contraceptive n=
15 Reasons for encounter: top-20 of ICPC-codes,2005 ( Reasons for encounter per 1000 patients per year, classified according to ICPC-chapter and gender, 2005) number of reasons for encounter male female all ICPC unknown A General & Unspecified B Blood D Digestive F Eye H Ear K Circulatory L Musculoskeletal N Neurological P Psychological R Respiratory S Skin T Endocrine & Metabolic U Urology P Pregnancy & Family Planning X Female Genital System Y Male Genital System Z Social Problems total number of reasons for encounter per 1000 patients
16 Digital triage, limited benefits limited decision support, medico-technology driven system rather than user-centered too defensive (medico-legal concerns); the greater part of advice referred to contact a doctor minority of complaints resulted in self-care advice limited consumerist empowerment high rate of drop-outs 50% by entering complaint 40% secondary drop-outs before getting advice used to prove assumptions (professional empowerment) rather than to make decisions when to contact a doctor
17 gatekeeper Digital triage, opportunities complaints similar to encounters for which a GP was contacted most according the top 20 encounters in the Netherlands complaints for which self-care advice could be given most complaints referred to non-urgent situations
18 Online surveys current users Survey (n=190) Intention to comply with self-care-advice demographics, reasons digital consult; use of digital consult expected and received advice factors that may influence intention to comply attitude advice (α=0.84) subjective norm (α=0.61) self-efficacy (α=0.88) severity of complaint (α=0.84) before and after submitting complaint) Follow-up survey (n=36) Actual compliance compliance with advice (yes, no) reasons non-compliance
19 Results survey Demographics n % Main reason digital consult (n=147) n % gender male information about complaint female advice if a GP should be contacted age in years mean 36.4/SD second opinion curiosity taboo-complaint 8 5 education level low middle information about medication other high 55 29
20 Results survey; evaluation advice, intention to comply no clear expectations about advice (n=93, expected: 29% GP-advice, 38% tailored self-care, 19% no expectations) majority received a contact-a-doctor advice (n=72, 76% GP-advice, 24% self-care advice) neutral to positive attitude towards advice mean attitude 0.42 (scale -2 to +2) positive about self-efficacy mean self efficacy 1.0 (scale -2 to +2) neutral influence (family, parents etc) on intention to comply mean social norm 1.3 (scale -10 to +10) slightly severe perceived complaints mean perception of severity (scale -2 to +2 (-2= non severe) neutral to positive intention to comply mean intention to comply 0.49 (scale -2 to + 2)
21 The compliance with a fully automated advice Determinants of intention to comply with advice (beta): - Attitude.69*** - Subjective norm.05 - Self-efficacy.08 - Severity of complaint.07 R 2 =.53 Determinants of actual compliance with advice (beta) - Attitude.21 - Subjective norm.26 - Self-efficacy.15 - Severity of complaint.08 - Intention to comply.72** R 2 =.47 ** p <.01; *** P <.001
22 Aspects that determine a positive attitude towards automated advice Expected usefulness understandable advice reliable applicable advice Effective reduced uncertainty, tailored to complaint
23 Opportunities digital triage Online patient-interviewing; diagnose, early detection of risks, preoperative screening matching QA-systems and users mental models Division of labor mid-level professionals (nurse practitioner s) e-triage centers E-service package chronic diseases digital triage, combined with online education, lifestyle interventions taboo complaints (urine-incontinency; Drs Kelders)
24 To foster empowerment via e-triage Organize e-care systems around patients/consumers How they think and frame their problems What they expect to be responsible for their own care and decisions What they need to support self-management of care Remove barriers and create enablers 50% referral to a doctor (24hrs) provides opportunity for self-care via online consultation enhance confidence in online consultation via easy to use and useful systems interoperable with Electronic Health Records
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26 Center ehealth Research Lisette van Gemert-Pijnen
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28 Reasons for encounter: top-20 of ICPC-codes,2005 ( Reasons for encounter per 1000 patients per year, classified according to ICPC-chapter and gender, 2005) number of reasons for encounter male female all ICPC unknown A General & Unspecified B Blood D Digestive F Eye H Ear K Circulatory L Musculoskeletal N Neurological P Psychological R Respiratory S Skin T Endocrine & Metabolic U Urology P Pregnancy & Family Planning X Female Genital System Y Male Genital System Z Social Problems total number of reasons for encounter per 1000 patients
29 Reasons for encounter: top-20 of ICPC-codes, 2005 ( Top 20 encounters primary care % K86 Uncomplicated hypertension 4,70 A99 Other general/unspec diseases 3,27 T90 Diabetes mellitus 2,80 P06 Disturbances of sleep/insomnia 1,35 P76 Depressive disorder 1,26 U71 Cystitis/other urin infect NOS 1,25 T93 Lipid metabolism disorder 1,19 R96 Asthma 1,17 R05 Cough 1,13 S88 Contact dermatitis/other eczema 1,01 R74 URI (common cold) 0,90 W11 Family plan/oral contraceptive 0,88 R97 Hayfever/allergic rhinitis 0,85 L03 Low back complt excl radiation 0,81 S74 Dermatophytosis 0,78 R78 Acute bronchitis/bronchiolitis 0,76 A97 No disease 0,75 R95 Emphysema/COPD 0,74 P01 Feeling anxious/nervous/tense 0,73 D12 Constipation 0,61 Other 44,28 Unknown 28,78 Total 100,00
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31 Center ehealth Research (IBR) Disease management Self-care management Critical dynamics health and wellness innovations Needs assessment, usablity-testing, testing, systematic review, KEA Seminars Workshops Publications Dissemination Online Life long learning tools heuristics design and implementation Client centered care
32 Projecten ehealthgw.nl Care coordination web-based information services (health care consumers, patients, health professionals, caregivers) cross-border ehealth Patient Care e-coach chronic complaints; monitoring, feedback, reminders, reinforcement programs e-triage (QA-systems for self-care support) e-consult (online communication and education) home health monitoring for continuity of care online discussion forums (self-help-groups) Promotion of Public Health internet for youth, portals
33 Chronic care model; kader voor interventies Impact op uitkomsten: Automated medical record Outreach and follow-up Registry Provider alerts and reminders Guideline distribution and training Provider financial incentive Care coordination Patient action plan Paul Wallace, Kaiser Permanente
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