Patient perspectives on tablet-based technology to collect risk factor information in primary care

There are increasing rates of chronic conditions related to modifiable risks including physical inactivity, smoking, and poor diet [1, 2]. Primary prevention strategies aim to increase physical activity, improve nutrition and decrease substance use to prevent associated morbidity and premature death [1‐9]. Individualized primary prevention counseling that considers the social determinants of health is associated with reduced risk behaviour as well as improved mental health and health outcomes [10, 11].

Primary care includes acute care, chronic disease management and services aimed at health maintenance. The Patient Centered Medical Home in the United States and Patient Medical Home in Canada supports team-based primary care [12, 13]. Primary care teams may include physicians, nurses and allied health professionals, who can promote health behaviors and implement primary prevention counseling [10, 12‐23]. Primary care counselling can be enhanced by priming the patient to reflect on their risk behaviors prior to their appointment with a clinician [24‐26]. Although patient-centered health risk assessments have a positive impact on primary prevention, [24] a recent study found that less than half of patient records had documentation of physical activity in the patient’s chart [27].

Algorithmic information technology to collect, organize and synthesize information about an individual has been employed in patient-directed mobile applications to support health behaviour change [17, 21‐24, 28‐35]. The Risk Factor Identification Tool (RFIT) is an algorithmic information technology survey designed by our team of researchers and family physicians [22, 23]. RFIT uses previously validated assessment questions and the trans-theoretical model to collect information on a patient’s risk behaviors, and readiness to change target behaviours prior to their annual health review with their physician [8, 32, 36‐41]. RFIT when connected to the patient’s Electronic Medical Record (EMR) contributes to a comprehensive record of risk behaviours that can inform personalized approaches to primary prevention. Previously, clinicians and clinic staff found RFIT to be a practical preventative tool in family practice [22, 23]. This study aims to assess the feasibility and integration of the tablet-based RFIT for collection of patient risk factors at primary care clinics, from the patient’s perspective. Analyzing RFIT and interview responses, complemented with the clinic’s experience, this study describes the use of RFIT and resulting primary prevention counselling at family practice clinics.

Of the 207 patients who started RFIT, 179 (86%) completed RFIT. On average patients took 11 min to complete RFIT. Approximately 3–4% of patients declined RFIT due to concerns regarding privacy, technology, appointment delays and language barriers.

Eighty-six patients (48.0%) who completed RFIT were interviewed. Patients interviewed were similar to patients who had completed RFIT. However, patients interviewed were older on average than patients who completed the tool (57.5 vs. 51.4 p = 0.001). They were also less likely to be employed (59.2% vs. 50.6% p = 0.04) (Table 1). Interviewed patients frequently reported that they were retired (n = 31/39.2%). Among the patients interviewed 95.0% reported that this was their regular healthcare provider and 80.0% had seen this clinician for more than 5 years.

This study implemented an algorithmic tablet-based tool in primary care that enhanced the collection of risk factor information. Implementing RFIT within primary care clinics provided information to the physician and facilitated immediate counseling following survey completion. Overall, the use of the tablet-based RFIT was well-received by patients of varying ages and socio-demographic backgrounds. The majority of patients had previous experience with a computer or tablet, however even patients without this experience were able to complete RFIT. RFIT presented an opportunity for patients to reflect on their risk behaviours, while providing information to the physician. However, there were some suggestions for improving RFIT and its implementation.

In previous evaluations RFIT’s use of information technology for the collection of risk factor information was favorably reviewed by clinicians and clinic staff [22, 23]. In this study, patients felt that the tablet-based survey was a well-designed tool for the collection of risk behaviour information. Patients were happy to occupy their time in the waiting room and very few patients required assistance with RFIT. Similar assessment tools, such as Case Finding Help Assessment Tool (CHAT) implemented in New Zealand, have been reviewed favorably by both clinicians and patients [21, 34, 35, 44‐48]. Although previous studies have suggested assessment tools should focus on psychosocial factors, this study found that tailoring the tool to the appointment type as well as population are important [34, 35]. Revisions of CHAT to support the collection of lifestyle and mental health factors from sub-populations have been favorably evaluated [46‐48]. Adjusting the RFIT questions and EMR integrated responses to the appointment type and patient characteristics can ensure specific details required to support behaviour change are available to the physician. CHAT identified that 35% of responders required assistance with a topic identified on the assessment tool [44]. We found that only 15% of patients reported that RFIT led to the discussion of a risk behaviour. Interestingly, while 9% of patients were flagged for alcohol use concerns, slightly more than half of these patients did not want to discuss their alcohol consumption with their physician.

Seventy-eight percent of patients we interviewed had been asked about one or more risk behaviours during the patient’s previous health review. Smoking is often the most common risk behaviour discussed [16]. However, counseling on physical activity (60.0%) was more common in this study. Lindeman et al. found that when physician encounters were reviewed the amount of physical activity documented ranged from 0.4 to 87.8% depending on the physician, and that the majority of patients with documentation of physical activity were patients with a chronic disease [27]. In this study 61.3% of patients had a chronic disease which may have contributed to the majority of patients having discussed risk behaviours in the previous year.

Patients in this study perceived RFIT as a beneficial, user-friendly tool. Patient suggestions about the tool sometimes contradicted design elements intended to make RFIT more user friendly for example avoiding open-ended questions. Patient’s positive assessment of the RFIT and resulting self-reflection supports the use of RFIT in primary care practices. Patient’s input in primary prevention counselling promotes a therapeutic alliance and is important in information exchange [49]. However, the use of RFIT responses by clinicians was variable. Patients reported not receiving counselling for a risk factor that they felt should have been discussed. Offering RFIT to new or infrequent patients may encourage additional review and better inform patient-clinician discussions. Additionally, although this study provided a list of resources to support behaviour change, clinicians and patients reported that they did not feel supported to make changes. Brief discussions and counselling in primary care can positively influence patients’ health habits including prevention activities (e.g. increasing physical activity) and health-promotion behaviours [14, 50]. Additional supports such as prescribing healthy behaviours and referral for more extensive interventions can provide comparative benefits for risk behaviours through connections with allied health professionals [50‐53]. Interventions must be supported by professional and personal relationships, attend to a patient’s health and social needs, and be designed based on individual patients interests to create new habits for health behaviours [6, 50, 54].

RFIT assisted in the collection of risk factor information from patients of varying ages and demographics. However, RFIT may be particularly useful for new patients or patients lacking continuity in their care. This study demonstrated that RFIT promotes patient self-reflection however, practical tools and resources are needed by providers and patients so interventions can be tailored to support reduction in risk factors. Future implementation of RFIT should be complemented with a team of allied health professionals prepared to support referrals from primary care.

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