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A computerized Health Risk Appraisal (HRA) administered in the emergency department (ED) at the University of Chicago not only drew enthusiastic reviews from patients but seemed to render those patients more willing to share sensitive information about lifestyle, health risk factors, and ongoing health problems. The program, recently detailed in an article in Annals of Emergency Medicine,1 was implemented with the goal of measuring four factors:
Participation required no computer knowledge. The screen was already set on the appropriate web site; a research assistant enrolled the inner-city patients and sat them down in front of the computer. Questions, written at a fifth-grade level, were answered by touching the computer screen.
The results of the study were impressive. Of 542 eligible patients (from nonurgent triage categories), 470, or 89%, participated. They were then randomly divided into a control group and a prevention group, which received the intervention. Of those receiving the intervention:
— 85% disclosed one or more major behavioral risk factors, including major depression (35%), unsafe sexual behavior (33%), current smoking (32%), problem drinking (19%), untreated hypertension (13%), use of street drugs (13%), and several other injury-prone behaviors.
— 95% of patients in the prevention group requested health information.
— On follow-up at one week, 62% of the prevention group (compared with 27% of the control subjects) remembered receiving advice on what they could do to improve their health.
"This is a doctor/patient communication tool that lowers the barrier that doctors and patients experience in bringing up difficult topics," notes Karin V. Rhodes, MD, of the University of Chicago Robert Wood Johnson Clinical Scholars Program, lead author and co-developer of the Prevent HealthQuiz.
Rhodes says there are a number of reasons behind the high response numbers. "A lot of research shows computer screening lowers barriers. Patients are more likely to disclose sensitive information on a computer," she says. (See "Related literature" at the end of this story.) Rhodes cites these two responses from a follow-up patient survey: "I liked that it was between me and the computer." "It’s easier to answer a computer than a person."
"Our patients were also very interested in getting information about their health," she adds. "In the course of taking the questionnaire, they could elect to get health information in addition to the recommendations they received, and 95% elected to do so." The No. 1 request, she says, was to learn CPR. "They also were interested in health information for others, like information on smoking," she notes. "This indicates the instrument has the capacity to extend the health promotion aspect to significant others."
Why were the patients more likely to remember health advice they got through the computer? "Maybe they were not getting that much information from the people who actually saw them," Rhodes posits. "Emergency medicine is problem-focused; doctors put all their effort into information gathering."
That is not intended as a criticism of ED physicians, Rhodes is quick to note. "Doctors want to do the right thing," she says. "We have to make it easy for them. It’s unreasonable to think that doctors should sit there and screen for seat belt use, how much people drink, and so on; the patients are perfectly capable of screening themselves. Then, you can focus on the positives — on targeting those risk factors that have been identified."
This method should prove to be more cost-effective, Rhodes asserts, because it does not require as much staff time. "Then, hopefully, it will result in meaningful communication between the doctor and patient about what can be done to improve their health," she says.
Finally, Rhodes notes, having patients complete this survey improves patient orientation and helps avoid disappointment and frustration over waiting longer than expected to see a physician. "Properly orienting patients as to what they can expect is critical to satisfaction," she says.
Responses to the satisfaction survey seem to bear this out. "We had 124 patients who volunteered their comments," Rhodes reports. "About 77% were extremely positive and 14% mildly positive. The more risk factors the patient had, the more they liked the HRA."
Rhodes has received a grant to further study and refine the Health Risk Appraisal instrument. "We’re now studying the effects of the tool and re-working it so it can be completed off the Web, and edited so it can be tailored to specific facilities," she reports.
1. Rhodes KV, Lauderdale DS, Stocking CB, Roizen MF, Levinson WL. Better health while you wait: A controlled trial of a computer-based intervention for screening and health promotion in the emergency department. Ann Emerg Med 2001; 37:3:284-291.
— Tourangeau R, Smith TW. Asking sensitive questions: The impact of data collection mode, question format, and question context. Public Opinion Quarterly 1996; 60:274-304.
— Hasley S. A Comparison of computer-based and personal interviews for the gynecological history update. Obstet Gynecol 1995; 85:494-498.
— Locke SE, Kowaloff HB, Hoff RG, et al. Computer-based interview for screening blood donors for risk of HIV transmission. JAMA 1992; 268:1,301-1,305.
— Robinson R, West R. A Comparison of computer and questionnaire methods of history-taking in a genitourinary clinic. Psychology and Health 1992; 6:77-84.
— Des Jarlais DC, Paone D, Milliken J, Turner CF, et al. Audio-computer interviewing to measure risk behavior for HIV among injecting drug users: A quasi-randomized trial. Lancet 1999; 353:1,657-1,661.
— Paperny DM, Aono JY, Lehman RM, et al. Computer-assisted detection and intervention in adolescent high-risk health behaviors. J Pediatr 1990; 116:456-462.