PDAs: Low Cost Technology to improve Health Counseling with Children and Teens

1. PDAs: Low Cost Technology to improve Health Counseling with Children and Teens PRISM-4 Conference January 17, 2008 Ardis Olson MD Dartmouth Medical School Ardis.Olson@dartmouth.edu

2. Challenges Screening in the Primary Care Setting • Limited time in visit Data gathering incomplete Sorting out clinician and parent agenda • Integrating new approaches into the office system Paper systems difficult to maintain • Changing established patterns of counseling by clinicians

3. “Healthy Teens” Projects Develop new approaches to health counseling in the preventive health visit • Robert Wood Johnson Foundation Prescription for Health National Program • Only adolescent focused project of 10 projects Utilize technology to optimize time available to clinician to discuss issues • Comprehensive health history/screening adapted from GAPS • Branching question path, if positive for risk behaviors • Additional assessments such as CRAFFT, eating disorders, sports risk screening • Assessed motivation and self-efficacy for change for 5 health behaviors • Confidentiality and Health Messages included during screening

4. What did we Screen For? • Health Concerns, Social and Medical History • Nutrition, Physical Exercise and Eating disorders • School, Home Environment and Safety Issues • Tobacco, Alcohol and Drug Use • Sexuality and Relationships • Mental Health, Abuse, and conduct issues • 66 Questions • Up to 25 additional questions if have risks

5. Question format seen by teen

6. Summary Report Total number of positives Tap stylus on the Question line and Takes you to specific Questions

8. Obesity Health Risks Ages: 11- 14 yrs 15-19 yrs < 5 fruit/vegs a day 58% 58% < 3 milk products 22% 26% > 2hr TV 56% 40% >1 hr computer/video 40% 46% < 3x/weekexercise 16% 26% Data on >3000 adolescents in NH/VT

9. Teen Readiness to Change for Diet or Exercise* Interested Important Confident Eating Healthier 11-14 yrs 58% 90% 84% 15-19 yrs 62% 89% 84% Exercise more 11-14 yrs 71% 83% 90% 15-19 yrs 70% 79% 82% *Among teens who screen positive for nutrition risk (60%) or inadequate exercise (24%)

10. Topics Discussed Comparison of the topics teens reported discussed prior to PDA use and after showed An increase in the proportion who discussed: Prior PDA Fruit/vegetable 45% 63% p=.03 Tobacco Use 43% 60% p=.04 Alcohol Use 41% 58% p=.05 No significant change in proportion who discussed ; Television viewing 35% 40% Exercise 66% 69% Milk product intake 47% 55% Drug use 41% 43% Mood issues 44% 45%

11. Teen View of Helpfulness of Discussion when topics discussed* Prior PDA use Fruit/vegetable intake (n=80) 32% 58% p=.03 Milk product intake ( n=74) 44% 70% p=.03 Exercise (n=99) 40% 57% p=.08 No significant change; Tobacco Use (n=74) 62% 70% Alcohol Use (n=73) 60% 61% Mood issues (n=62) 38% 53% Drug use (n=59) 61% 67% TV viewing (n=53) 35% 40% *Among teens with topic discussed, the proportion who responded discussion was very helpful vs somewhat/ not helpful

12. Changing how the interview is done • Asking permission to discuss a topic • Jointly set the agenda about what to talk about • Not giving scripted advice but engaging teen reluctant to change risk behavior in discussing pros and cons of the health risk • Problem solving action steps and barriers when ready to change

13. Outcomes: Interaction with teen More teens felt their provider listened very carefully* to them during the visit: 63% before PDA 88% with PDA use p <.01 More teens were very satisfied* overall with the visit 64% before PD 88% with PDA use p <.01 *1 on a 7 point Likkert scale

14. Views of Clinicians who have used PDAs with teens • I know my patients better and feel like I more thorough • Helps bring sensitive issues up for discussion • Increased confidentially and more honesty in teen responses • Focuses visit on important issues • Teens more open to discuss issues first introduced through the PDA

15. Change in health behaviors • Comparison of 136 teens prior to PDA to 148 teens in same practice the next year with PDA • Exit surveys and follow up 6 months later • Teens with health visit using the PDA: • More likely to leave the visit with a specific plan to change for nutrition/sedentary behavior • More likely to plan more action steps • Increased number of days with 30 minutes of exercise • Decrease in hours of television watched if ready to change and discussed with clinician

16. Healthy Families Project • 4 community practices in rural New Hampshire with Pediatric and Family Medicine health providers (population 2,000 to 15,000) • 1585 parents at well visits of their children ages 4 to 10 years have completed pre-visit screening utilizing a hand held computer (PDA) • Clinicians training to use brief motivational interviewing techniques and provided via the PDA: 1) child’s BMI and BMI Percentile 2) obesity related health risks, 3) each parent’s motivation to change for nutrition and activity, 4) counseling prompts for motivational interviewing • 6 month follow up of families in process

17. Concerns about your child that you wish to discuss today

18. Nutrition

19. Family

20. Activity

21. Safety: Does your child use:

22. Social/emotional *PHQ-2; each question score added and flagged as +if >3

23. PDA information

24. PDA Summary Screen

25. Counseling cues if ready to change

26. PDA Counseling Cues if Not Ready to Change

27. PDA Counseling Cues if Unsure

28. What Clinician knows at start the visit using the PDA • If BMI % for age is 85% - 94% or ≥ 95% • Health behavior risks (Nutrition, Activity, Family risk) • Any issues about development/behavior/school/safety • Social and parental depression risks • Readiness to change eating/physical activity • Parent view of importance to change for both physical activity and nutrition (1-10) • Parent view of confidence to change for both physical activity and nutrition (1-10)

29. What we have learned • 96% of all children have a nutrition risk: <3 fruit or vegetables/day, < 3 milk products/day, > 1 sweetened beverage/day, fast food, or second helpings 2 or more times/week 65% of all children have a sedentary behavior risk > 2 hr TV or>1 hr video/computer use/day, or <1 hr/day active play

30. What we have learned when child has BMI >95% • 53% interested in making changes for their child to eat healthier when risk present • 30% interested in making changes for their child to be more physically active when risk present

31. Implementing a New PDA Approach in the office • Office clinician champion • Consistent approach across clinicians easier for staff • Office staff key to having done • Explaining to staff • Insuring consistent use • Periodic review by staff and clinicians • Problem solve issues • Share successes • Revise procedures

32. Next Opportunities • Maine half day conferences this spring for implementing PDAs • Clinician and Office staff nursing leader • Training in use of PDA Setting up a PDA system Synchronizing data to web to view summary data of practice • Clinician training in use of the PDA in the clinical encounter • Provided with PDA software for and first PDA at discount

33. Conclusions about the use of PDA technology • Efficient comprehensive data gathering • Prepares teen or family to discuss changes in health behaviors • Confidential • Early studies show visit improved and teens make changes after the visit.