The effect of EHR-integrated patient-reported outcomes on satisfaction with chronic pain care.

OBJECTIVES: Given its complexity, chronic noncancer pain presents an opportunity to use health information technology (IT) to improve care experiences. The objective of this study was to assess whether integrating patient-reported outcomes (PROs) data in an electronic health record (EHR) affects provider and patient satisfaction with chronic noncancer pain care. STUDY DESIGN: We conducted a pragmatic cluster randomized trial involving 4 family medicine clinics. METHODS: We enrolled primary care providers (PCPs) and their patients with chronic noncancer pain. In the first 7 months (education phase), PCPs in intervention practices received education on how to use PROs for pain care. In the second 7 months (PRO phase), patients in intervention practices reported pain-related outcomes on arrival at their visits. PROs were immediately reported to PCPs through the EHR. Control group PCPs provided usual care. We compared intervention and control practices in terms of provider and patient satisfaction with care. RESULTS: During the education phase, patients' mean ratings of their visits did not differ between control and intervention (9.33 vs 9.08; P = .20). During the PRO phase, patients' mean ratings did not differ between control and intervention (9.28 vs 9.01; P = .20). Similarly, there were no differences between the intervention and control groups in terms of provider satisfaction. CONCLUSIONS: Delivering EHR-integrated PROs did not consistently improve patient or provider satisfaction. Positively, we found no evidence that the PRO tools negatively affected satisfaction. Future studies and technological innovations are needed to translate point-of-care health IT tools into improvements in patient and provider experiences.

Novel Application of a Reverse Triage Protocol Providing Increased Access to Care in an Outpatient, Primary Care Clinic Setting.

BACKGROUND AND OBJECTIVES: As the number of patients with access to care increases, outpatient clinics will need to implement innovative strategies to maintain or enhance clinic efficiency. One viable alternative involves reverse triage. METHODS: A reverse triage protocol was implemented during a student-run free clinic. Each patient's chief complaint(s) were obtained at the beginning of the clinic session and ranked by increasing complexity. "Complexity" was defined as the subjective amount of time required to provide a full, thorough evaluation of a patient. Less complex cases were prioritized first since they could be expedited through clinic processing and allow for more time and resources to be dedicated to complex cases. Descriptive statistics were used to characterize and summarize the data obtained. Categorical variables were analyzed using chi-square. A time series analysis of the outcome versus centered time in weeks was also conducted. RESULTS: The average number of patients seen per clinic session increased by 35% (9.5 versus 12.8) from pre-implementation of the reverse triage protocol to 6 months after the implementation of the protocol. CONCLUSIONS: The implementation of a reverse triage in an outpatient setting significantly increased clinic efficiency as noted by a significant increase in the number of patients seen during a clinic session.

Overcoming barriers to implementing patient-reported outcomes in an electronic health record: a case report.

In this case report, the authors describe the implementation of a system for collecting patient-reported outcomes and integrating results in an electronic health record. The objective was to identify lessons learned in overcoming barriers to collecting and integrating patient-reported outcomes in an electronic health record. The authors analyzed qualitative data in 42 documents collected from system development meetings, written feedback from users, and clinical observations with practice staff, providers, and patients. Guided by the Unified Theory on the Adoption and Use of Information Technology, 5 emergent themes were identified. Two barriers emerged: (i) uncertain clinical benefit and (ii) time, work flow, and effort constraints. Three facilitators emerged: (iii) process automation, (iv) usable system interfaces, and (v) collecting patient-reported outcomes for the right patient at the right time. For electronic health record-integrated patient-reported outcomes to succeed as useful clinical tools, system designers must ensure the clinical relevance of the information being collected while minimizing provider, staff, and patient burden.

Can behavioral theory inform the understanding of depression and medication nonadherence among HIV-positive substance users?

Medication adherence is highly predictive of health outcomes across chronic conditions, particularly HIV/AIDS. Depression is consistently associated with worse adherence, yet few studies have sought to understand how depression relates to adherence. This study tested three components of behavioral depression theory--goal-directed activation, positive reinforcement, and environmental punishment--as potential indirect effects in the relation between depressive symptoms and medication nonadherence among low-income, predominantly African American substance users (n = 83). Medication nonadherence was assessed as frequency of doses missed across common reasons for nonadherence. Non-parametric bootstrapping was used to evaluate the indirect effects. Of the three intermediary variables, there was only an indirect effect of environmental punishment; depressive symptoms were associated with greater nonadherence through greater environmental punishment. Goal-directed activation and positive reinforcement were unrelated to adherence. Findings suggest the importance of environmental punishment in the relation between depression and medication adherence and may inform future intervention efforts for this population.

Distress tolerance and use of antiretroviral therapy among HIV-infected individuals in substance abuse treatment.

Despite recent clinical guidelines recommending early initiation and widespread use of antiretroviral therapy (ART), many HIV-infected individuals are not receiving ART-in particular low-income, minority substance users. Few studies have examined psychological, as opposed to structural, factors related to not receiving ART in this population. Perceived capacity to tolerate physical and psychological distress, known as distress tolerance (DT), may be a particularly relevant yet understudied factor. The current study tested the relationship between self-reported physical and psychological DT and ART receipt among predominantly low-income, minority HIV-infected substance users (n=77). Psychiatric disorders, biological indicators of health status, ART use, structural barriers to health care, and self-reported physical and psychological DT were assessed. 61% of participants were receiving ART. The only factors that distinguished individuals not on ART were greater avoidance of physical discomfort, higher psychological DT, and higher CD4 count. Both DT measures remained associated with ART use after controlling for CD4 count and were associated with almost a two-fold decrease in likelihood of ART receipt. Current findings suggest higher perceived capacity to tolerate psychological distress and greater avoidance of physical discomfort are important factors associated with lower ART use among substance users and may be important intervention targets.

Rumination Mediates the Relationship Between Distress Tolerance and Depressive Symptoms Among Substance Users.

Distress tolerance has been implicated in the emergence of internalizing symptomatology, notably depressive symptoms. However, few studies have tested potential mechanisms underlying the relationship between distress tolerance and depressive symptoms, and further, this has not been tested among substance users, who commonly experience both low distress tolerance and elevated depressive symptoms. The current study focused on the construct of rumination, which has been suggested to be a coping response to stress associated with substance use and depression. Two forms of rumination, brooding and reflection, were tested as potential mediators of the relationship between distress tolerance and self-reported depressive symptoms among 128 individuals entering substance abuse treatment. Brooding (i.e., to overly focus on symptoms of distress) mediated the relationship between distress tolerance and depressive symptoms. However, reflection (i.e., to attempt to gain insight into problems) was unrelated to distress tolerance. Findings suggest the important role of brooding as a mechanism underlying the relationship between distress tolerance and depressive symptomatology.