Provider reactions to an automated telephone tool to screen and monitor depression in a safety net population

摘要

As practice recommendations and guidelines accumulate, the healthcare system continues to depend on clinician heroes to work harder and faster to meet increasing demands. Population health management requires healthcare to move towards systems based designs, and move away from depending on individual patient visits. However, the implementation of a change in care delivery has to be endorsed by providers or it is doomed to fail, and frontline providers can singularly provide critical insight into the successes and failure of the system. The Diabetes-Depression Care-management Adoption Trial (DCAT) is evaluating an automated telephonic assessment tool for depression in a primary care setting. The technology tool was designed to shift routine depression screening and symptom monitoring from providers to machines and used the information to automatically alert providers of those patients in need of follow-up. Therefore, providers can have more time dedicated to proactive, compassionate care. This article first proposes a conceptual framework for evaluating provider responses to such system-based redesign of healthcare delivery. The conceptual framework focuses on barriers to providing recommended care, the success of the information system implementation, and the role of cultural and organizational characteristics. This framework is used to evaluate survey responses from 12 providers who provided care to 1406 patients in the DCAT trial. The survey included 7 respondents from sites using the technology tool, and 5 from sites not using technology tool across the professional spectrum (nurse practitioner, registered nurse, social worker, and licensed vocational nurse). The results showed that providers at sites using the technology tool more frequently spent time providing care (e.g., monitoring adherence to treatment, monitoring side effects, and adjusting the treatment plan), whereas providers at sites not using the technology tool more frequently spent time on identifying patients' care needs (e.g., routine screening and assessing for depression episodes). Outcome expectancy and satisfaction was significantly higher in the sites with the technology tool, whereas knowledge was significantly higher in the control arm. Self-efficacy and familiarity were not different between the two groups. The conceptual model creates a framework for understanding the impact of healthcare delivery system redesign on providers. Preliminary survey results show that providers with access to the automation technology spent less time on routine processes of care, and more time on patient-centered care. Furthermore, system change may result in changes in provider confidence and satisfaction without impacting skills or beliefs.