Background
Interactive eHealth tools, mental health & primary care
Methods
Study setting
Ethics, consent and permissions
Intervention
Design and procedures
Data collection
Computerized Lifestyle Assessment Scale mean (standard deviation) | |
Perceived Benefits, overall mean 4.1 (0.7) | |
1. I would feel comfortable answering questions on a computer. | 4.3 (0.8) |
2. The computer is a good way to ask about social and emotional issues. | 4.3 (0.7) |
3. It would save the provider’s time. | 4.1 (0.9) |
4. Computer-assisted risk assessment will help providers with questions on social and emotional health. | 4.0 (0.8) |
5. Providers will make better health assessments with such computer systems. | 3.9 (0.9) |
6. Computer-assisted health risk assessment can be trusted. | 3.9 (0.9) |
Perceived Privacy-Barriers, overall mean 2.6 (0.8) | |
1. I would worry about confidentiality when completing computer survey. | 2.9 (1.2) |
2. I do not want certain information about me on computer. | 2.7 (1.1) |
3. Too many mistakes will be made with the computer-assisted risk assessment. | 2.3 (0.9) |
Perceived Interaction-Barriers, overall mean 2.8 (0.8) | |
1. Providers would spend less time with patients. | 3.2 (1.2) |
2. There will be loss of personal communication with a provider. | 2.8 (1.1) |
3. I would find another provider with no such tool. | 2.4 (1.0) |
Quality Assessment, count (percentage) | |
Using the touch screen | |
Very Easy | 62 (83.8) |
Easy | 10 (13.5) |
Difficult/Very Difficult | 2 (2.8) |
Following the survey instruction, count (percentage) | |
Very Easy | 51 (68.9) |
Easy | 18 (24.3) |
Difficult/Very Difficult | 5 (6.8) |
Reading the questions on screen, count (percentage) | |
Very Easy | 61 (82.4) |
Easy | 9 (12.2) |
Difficult/Very Difficult | 4 (5.4) |
Acceptable time for survey completion, count (percentage)
| |
Yes | 70 (94.6) |
No | 4 (5.4) |
Analysis
Results
Participants
Client perspectives
Provider perspectives
I’ve been here long enough to realize the prevalence of underlying mental health conditions… I almost have an assumption that there are mental health issues unless I’ve found otherwise. There’s the whole stress [of] migration but [I] do not denounce the various degrees of resilience in the population (FP#1).
We have frequent utilizers of our services, … we see numerous appointments for somatic complaints that don’t have any readily [available] explanation [of] the vague symptoms (FP#1)So often with our patients, especially with the complexity of other issues, we need to deal with multiple issues at each visit, and so as we all know mental health takes a lot of time to—to even screen properly, diagnose, and assess. So it’s often hard to find the time to be able to do that in routine visits. (FP#6)
They are usually coming in presenting with a different issue; then the mental health issues are sort of teased out, or come up, during the interview. You don’t really have much time to address them. Because they may come in thinking they have a pain in their foot and then it end up having something else. So, time constraints. (FP#4)
The interpreters, they have the skills and they’ve done the training but they are from the same community. … [Patients worry] that message will be carried back to their community … Even though, privacy laws [exist]… They know that whatever they say is actually not just being said through the interpreter but is being said to [the person] also. There are all these little intricacies when you think of somebody who is not English speaking being able to tell you how they feel. (NP#3)
There is a big stigma attached to mental illness so even if the client themselves wants to disclose how they feel the relative that has brought them, because they are feeling so low and so down, [They] says “Oh it’s not so bad.” (NP#3)[this is a] vast over-generalization, but a lot of the sub-Saharan African countries I find don’t have this culture. It’s like…mental health doesn’t exist. A lot of the South Asian communities as well, so especially like our North Koreans and our Bhutanese population as well. … Some people have very negative views on it. (FP#3)
I guess it’s to put the person in the head space to get them thinking about their mental status, because they already have an agenda in their head when they first arrive. (NP#3)It’s good for patients that would want to sort of self-manage or start things on their own. (NP#6)
Sometimes it’s easier to talk to a computer that is “blank.” Then they can say exactly what they want to say. If they are in front of a person then no matter how blank you keep your face, which you never do, you always try to be pleasant. … Where as to a computer, if you’re feeling low, they can be low, there’s no expectation of how they are supposed to behave. So, I think it’s easier to express how you feel, although, there is something to be said with empathy, so that you can draw things out. But certainly as a starting tool, for screening … (NP#3)
I think at least in a few instances … it did have a positive influence on the patients. It was almost another affirmation that they were having issues and something else to speak to, not necessarily to provide diagnosis or treatment, but a recognition. (FP#1)
Maybe it was a matter of their confidence being bolstered by the fact that they have something there that was an objective measure. They could show me….and stimulated a few of them to address it at that appointment and allow me to address it more easily (FP#1)I think they are happy to have someone else [who] is willing to listen. At the same time, providing the resources that they probably need. Many people forget about what’s available … they don’t know what’s available out there. (NP#4)
I think it’s really good, I think that it brings a lot too as far as screening, I could definitely see value in—in like the general practice as far as having those questions asked for you so you’re sort of bringing in and it will trigger the discussions around it. [I] t’s user friendly and you know it’s used quickly to interpret the results. (NP#5)
I guess it was a little plain. It had titles. I did not have difficulty reading it. My eye was drawn towards different things. And the fact that suicidality was highlighted … it was a really good thing. It made me go “ohhh.” And I thought about our discussion and I was not worried about his safety. (FP#4)
Absolutely. It definitely saved me time because a couple times things were flagged on that form that I didn’t previously know about or I wouldn’t have asked about based on the nature of our visit type that particular time. So, it is good to know because it did impact my care plan. So, I think it was beneficial but it is also something that I wouldn’t have otherwise known about because I probably wouldn’t have taken the time in that particular instance to identify it. (NP#1)It’s a screening tool. I did have one young lady who had potentially a problem with abuse in the home and that was pulled out. I was very grateful for that and another woman who was suffering from a lot of stress that was bringing her down to a low grade depression. I remember those clients. And I remember the little piece of paper but the one with the abuse had at the bottom of it all the links to where they could call. (NP#3)
To be honest I think a lot of the time the patient came in for a totally different reason, like knee pain or something like that and so they want to talk about the knee pain and by the time the appointment was over there was no time to talk about the iCCAS study. (FP#2)
There were a couple instances where the severity was a lot higher than I had anticipated and I queried the patient after the fact … in a couple instances they may have misinterpreted … they seemed to have answered the questions in terms of “in the past have you had this level of depression” … they weren’t necessarily relating it to the most recently [2 week period]… they were just answering about their worst experiences. (FP#1)
No [it did not interfere with the visit], I think the only thing was time. As long as the patient was ok with starting the visit earlier with you and ending a little bit later with our visit. I think that it generally was well received from their perspective. I mean, I’m usually on time with my appointments and I never felt I had to wait for very long. Maybe a couple minutes. But it didn’t impact the flow of any of my appointments any further. (NP#1)
So, you know, the report itself goes into the EMR as opposed to the desk so it becomes part of the person’s chart. And if we wanted to do it on a regular basis. So, for a screening, say someone tests positive for things, then it could … alright, let’s get this person to do it again in 6 months’ time. (FP#4)
I am just trying to think of whether there would be a more optimal implementation time or period. We used to have an hour for initial appointments with our clients and you used to be able to flesh out some of those other mental health issues. It would need to be incorporated where there was an initial say 15 minutes at the beginning … an extended appointment perhaps to implement it … I don’t even know if it is realistic in this office. (FP#1)Actually I think that would be a very strong thing. [It] should actually be part of our routine, [once a year]. (FP#3)
We are so tuned in to mental health. It is a huge priority as an agency. This, although it is great and helpful and I like the concept, I think it would be much more of a benefit to an organization that is not so tuned in to mental health. (FP#4).Table 2Participating Providers’ Themes and Sub-Themes
Themes Sub-Themes Quotes Providers’ challenges in assessing mental health Complexity and severity of cases One of the challenges, not only for mental health issues, but other chronic illnesses is that a large majority of my patients will only come to their appointments when they need something from me in particular. Not necessarily a medical issue. A lot of times it’s other issues related to filling out forms or seeking disability or stuff like that. So that can be a challenge…and a lot of times there is a lot to address in an appointment. (FP#1) Time I would say the biggest reason is time. If a person doesn’t come with a complaint that might warrant that discussion, it tends not to be talked about. And for someone who is coming in with various episodic things, that could potentially not be addressed for a long time or ever. (NP#1) Language barriers The biggest challenge would be in language. Because the way people present how they feel to the practitioner doesn’t necessarily reflect how they are feeling inside themselves. So, even if you have an interpreter, you’re not getting that nuance. (NP#3) Interpreters When I’m having numerous patients back-to-back that require interpreters… it is not uncommon that they are scheduled like that instead of being interspersed with English-speaking clients where you can often make up some time. (FP#1) Mental health stigma There’s definitely a stigma … Especially across cultures. It’s hard to really know from person to person and culture to culture because everyone [is] experiencing things differently. (NP#1) Vulnerable population I think we have a big sort of burden of disease with mental health issues in the community health centre sector and ours as well. A lot of the clients that we see have more resistant or pervasive mental health issues, whether it’s post-traumatic stress disorder …we do have a lot of people who spend a lot of time waiting to come and be processed, to come to Canada as refugees (NP#5) Perceived benefits of using iCCAS Clients: self-awareness I think [clients] appreciated it. I think for them, it was helping to unload a very big burden on them. So, I think it’s one more thing that took a little bit of the burden away. (NP#1)I think that the value of it in this setting is tuning people into their own mental health, showing people what resources are available, and, “Oh, why don’t you talk to this person?” and it also gets people to start thinking about their mental health. FP#4) Clients: disclosure They felt more comfortable [talking about mental health] because they had already written it. They’ve already expressed it. Now they can build on what they had expressed. It wasn’t a new thought for them. It was very helpful. (NP#3) Clients: normalize I also find that the last part that says recommendations has been really helpful too. Pretty much all of them say referral to social work, so I thought that that was really good because it [is] something that, normalizes it and it says that anyone can really benefit from this service so feel free to take advantage [of] …we’ve it available to you for free because it’s part of our organization and what we value. (NP#1) Clients: non-invasive [The clients] entered all these symptoms and they think I have a problem rather than like a doctor telling you that you have a problem. (FP#2)For the provider point of view, there might be some things that come up because the iCCAS asked the question in a different way, or they are sitting there alone and their impulse is to answer in one way, while when they are in front of me their impulse is to answer another way. (FP#4) Clients: point-of-care feedback It has the resources in it as well, so I think—it’s been a while since I saw one smokers’ helpline, there’s an alcohol one, there’s abuse, abuse, like, contact numbers for more information. (NP#5) Clinician: effective/efficient screening tool I think it has a benefit, there are times when I’m dealing with the physical needs of the patient, but if I get the report it sort of alerts me to look into that part too… I don’t forget the mental part. (NP#2) Clinician: useful report No, I think it’s quite clear. I usually only look at the left-hand side. That’s the main thing I look at. (NP#2) Clinician: identify new cases The couple of times I had actually seen it was on a couple of people I was already managing their mental health issues. I think here mental health is very much front and centre. Both in the provider’s mind and also with the patients. It tends to come up more. So what the iCCAS report did for me was simply to solidify what was going on. Although there was one where it said that the person was feeling suicidal and I didn’t realize they were having those thoughts. So that would have been important. (FP#4) Perceived challenges in using iCCAS Time & many issues Sometimes, not always, but often we will know about the mental health issues, or there’s other things that are pertinent to deal with at the time. (FP#3) Receiving iCCAS report [The report] was sort of handed to me sometimes even in the middle of a visit, or when I had already started dealing with whatever issues. (FP#3) False alarm/ misinterpretation There was an incident from iCCAS; it [the report] says “patient suffers severe depression and intention of hurting herself,” (…) but when I looked at the iCCAS report and I asked the patient … the patient goes “No, I’m fine, I don’t want to hurt myself or others.” I charted it too and I tried to follow up, the patient does have depression, but no intention of hurting themselves, so that was a little bit,… I don’t know what happened there. (NP#2) Interest in integrating iCCAS into everyday practices. Integration into regular practices The more you can get yourself out there to discuss mental health, the better. So if there would be a way of being involved in the community’s services sector of Access Alliance for some of their programs or maybe not necessarily getting the entire group but getting a few people in the group that might be helpful, as well. (NP#1) iCCAS’s ability to promote better service It would be a great way to advertise our community programs. That’s another thing, I sometimes find that the primary health care team and the community health program team are disconnected in a way… I find that I identify a lot of patients that could benefit from these programs and what I will do is, I’ll either write it on a piece of paper to say, “Hey, we have a community users desk at the front,” … but it just gets lost sometimes, sometimes that lady is just not there, a lot of that happens, maybe this is a good way. (FP#2) Promoting an effective integration of iCCAS into primary care practices Different languages I think definitely to have it in other languages, and especially because our population…Yeah, like Farsi and Dari, like we have a lot of Afghan patients who again conceptually they don’t necessarily have the vocabulary around it. Korean… (FP#3) Integration with EMR It’s good to incorporate with the computer system, the EMR system, also, it can be accessed though, by other clinicians, like a social worker can look at it. (NP#2) Time of the screening I think it would be great for initial visits. If it can be timed with the initial visits, or pre-screening before people are seen at the clinic. … So if we knew that information before even seeing the patient, I think that would be very helpful as opposed to just dropping it in the middle of—of managing patients. (FP#3) Other primary care settings The clinicians who work here, we all try very hard to stay on time. But, for example, the previous clinician he would see people and fit-ins and all of that. So that might of worked better for him. For us the—yeah the clinicians that were working during the iCCAS study are quite on time. … whereas at another practice maybe that wouldn’t be the case. And I think most doctors’ offices people don’t run on time until it might be easier to catch people when they’re in wait—in the waiting room. (FP#3)