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Electronic tablets help provide information
Sensitive questions not always answered face-to-face
Patients at Duke University Hospital's cancer clinics have begun using electronic tablets to complete questionnaires about their health situation, and staffers are extremely pleased with the results. For one thing, they note, patients are less reluctant to answer sensitive questions, the answers to which can provide physicians and nurses with important information about the care they require. As a matter of fact, they note, the e-tablets have actually helped uncover new opportunities for improvement.
"For example, sexual distress had been sort of a hidden problem; we had no idea," recalls Amy P. Abernethy, MD, director of Duke's Cancer Care Research Program. "It was one of their main concerns, and they had no way to deal with it."
This led to new research, and a number of published papers, says Abernethy. Nurses were brought up to speed and patient education needs were addressed. However, the level of patient distress had still not changed.
"So we went to a psychologist and asked what kinds of interventions were needed," Abernethy continues. "They suggested some coping interventions, and we got funding for providing those interventions if a patient reached a certain level of stress; if the patient agreed, they got randomized to research a type of coping intervention."
Once she knows that an intervention is working, she says, "we will put it back in the system as a standard. Meanwhile, the knowledge also allowed us to engage a urologist and gynecologist who had never before engaged in my cancer care. We were able to show an influence on quality of life."
"I'd say it's a really nice added bonus and tool for taking care of very sick patients," adds Susan Blackwell, MHS, PA-C, senior physician assistant, thoracic oncology and sarcoma, Duke University Medical Center. "These oncology patients have lots of issues going on; it makes our dictation more complete, and we can refer back to it. We do not have to write down all the patient says, but we can add to it and when it's time to do dictation, I dictate from it and my notes may be more complete than by just talking to patients and trying to remember all the questions I asked them."
The greatest benefits, she continues, have probably been in the psychosocial area. "That's where we're likely seeing the biggest improvement for our patients; we find out how many people really are having a lot of distress and worry," she explains.
Of course, she continues, many cancer patients note they are in pain or experiencing nausea, but they also indicate depression and anxiety. "Now, this enables our therapists and counselors to become more and more involved," Blackwell notes. "Some of these issues we may have missed because a lot of these are things people do not like to admit."
"It enables us to approach patient triage more smartly," adds Abernethy."By dividing people up by level of distress, we have all these different types of social care services; we never before had a way of matching up the service to the person."
How the tablets work
When patients check in at the front desk, they are greeted either by team leaders or undergraduate students who are well trained in the tablet and how it works, Blackwell explains. "If they are new, they get an explanation of what it is and why we're using it," she says. "Patients who are more familiar are given a tablet and asked if they would mind filling out the questionnaire."
After the questionnaire is completed, it is transferred electronically and a printout is created. "It immediately tells us which cases are having high distress or symptoms, because they mark them on a scale; they are then color-coded as severe or moderate or low," Blackwell explains. "So if we see orange, for example, we know that's not good; it only takes a second to see if patients are having a lot of problems."
The primary nurse sees the printout first, she continues. "A lot of times they will initiate a call to our counselors or therapists if the patient reports a lot of anxiety or depression; that happens automatically, which we never did before," says Blackwell.
The color scale works like this: five or six is coded yellow, while eight or higher receives an orange. "There is also a very complete list of symptoms the patient can look at pain, nausea, vomiting, constipation, rash, and so forth," notes Blackwell. "If we get a printout and everything is completely white, we know that the patient either didn't fill out the questionnaire or they are doing fine and not having any problems."
When the provider sits down with the patient face to face, she continues, they are shown the document and what they wrote, and then "a more directed conversation" can begin.
Another benefit of the printout, Blackwell adds, is that "you can look at the printout from the previous visit so you see if the interventions have helped."
'Nominal' training required
Abernethy says that "nominal staff training" was needed for the tablets, which have been in use in some Duke clinics for about 18 months (they have been rolled out gradually). "We have one person, who is usually a student, who troubleshoots any computer problems," she says. "The biggest part of the training was teaching nurses how to interpret and respond to reports and we're still figuring that out. There are many things people complain about that the nurses need to be addressing.
"We've actually adapted the tablets and are working with the government to create an open-source version that will have most of the same features," she adds. Abernethy says that Duke purchased about 100 units for about $200,000.
She adds that she is very pleased with the results so far."I see the need to upgrade from where we are to the next level, but that's OK I always knew we would," she says. (For example, Blackwell says she used the e-tablets at a previous position that enabled patients to indicate the need for prescription refills.)
"There's one thing I'd like to stress," says Abernethy. "Make sure your system is secure and trustworthy." In addition, she notes, it's important to survey patients often on how to improve the system.
For other facilities considering using e-tablets, she adds this is a "critically important" point. "It's education," she says. "After the patient has finished doing the survey here, they are actually matched into an electronic patient environment that includes videos, PDFs, and so on, and I can choose what information and education they should get. If they have a specific problem, like insomnia, I trigger specific information." Educational materials, she adds, "are what patients want most."