February 5, 2014

The Ideal Tool for Health Care: Patient Perspective

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Larry Culpepper, MD, MPH

Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts


In my blog post on January 8, 2014, I took the position that the question of whether we should consider ending routine screening for major depression, as the Canadian Task Force for Preventive Care is recommending, is largely irrelevant to the United States context. Here, after years of fragmentation, we are integrating mental health care into the patient-centered medical home (PCMH). Therefore, we should be considering the attributes of the ideal tool to guide mental health care in the PCMH. The overall goals of such a tool are to increase the efficiency, completeness, accuracy, and validity of mental health information available to the clinical team, both initially and over long-term follow-up, and to support and guide the team and patient in managing care.

The patient perspective is perhaps the best place to start. A tool should be accessible 24/7 from multiple platforms linked to the web portal of the PCMH. For some patients and uses, its components also need to be available on paper. The online tool should be interactive and “smart” in adapting follow-up questions to prior responses. It should have a memory and be individualized to a patient’s language, education level, and cultural background. This ideal tool should allow the patient to help guide interactions. It should transparently promote predictable communication with the patient’s treatment team, including about patient preferences and concerns.

How would using this tool “feel” to a patient? A valuable tool for patients will ask not only how they feel internally but also how they are functioning and fulfilling their roles in their families, at work, and in their social relationships. An initial interaction might start not with a screening of symptoms but instead a clarification of the patient’s level of functioning and his or her concerns regarding functioning. What are the patient’s strengths and weaknesses, such as in family and social relationships and in material and intellectual resources? This tool should support the patient in identifying and communicating his or her priorities and concerns related to functioning to the care team.

Next, clarifying the patient’s history of psychiatric illness might follow, with the online tool both populating fields with any relevant information that is already in the record and querying the patient for more data. Has the patient ever been depressed, anxious, manic? Ever been given a diagnosis or treatment? If so, what was his or her experience with it, and what are his or her treatment preferences? What are the patient’s particular vulnerabilities—eg, is there a history of early abuse and neglect or past major trauma, or is there past alcohol abuse?

With the above information collected, symptom-level screening then becomes relevant to establish a current snapshot of the patient, including any already known disease, and to expand on the patient’s concerns. To ensure that patients without voiced concerns are not minimizing symptoms, positive initial responses can lead to more detailed query.

Is such a tool pie in the sky? Currently, yes. But, consider. Its key functions are to provide a “checklist” of complete information to be obtained from the patient and to ensure that the information is communicated to clinicians and followed up. These tasks, if done face-to-face, can be overwhelming for patients and clinicians. Distillation and organization of this information, however, would be of great usefulness in enhancing the relationship between patient, clinician, and treatment team.

If done using virtual tools, including interaction with a virtual patient advocate on the PCMH web portal, clinician time could be conserved and channeled very efficiently. Patients could interact with the tool at their own pace and at convenient times. With such information flowing, patients, aware that their clinicians and treatment teams have a robust understanding of them (much more than is possible in 10 or even 30–60 minute interactions), can develop increased confidence in the care received, their ability to participate meaningfully in treatment decisions, and consequent adherence and engagement with treatment.

We already have the building blocks for such an instrument, which I will describe in my next blog entry, along with the treatment team’s perspective on the ideal health care tool.

Financial disclosure:Dr Culpepper is a consultant for Forest, Lundbeck, Merck, Sunovion, and Takeda; has received travel support from Pamlab; and is a stock shareholder of M3 (My Mood Monitor).

Category: Medical Conditions , Mental Illness
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