Use of an Online Clinical Process Support System as an Aid to Identification and Management of Developmental and Mental Health Problems

Abstract

Purpose of Review

The purpose of this review was to describe benefits and problems with screening and addressing developmental and behavioral problems in primary care and using an online clinical process support system as a solution.

Recent Findings

Screening has been found to have various implementation barriers including time costs, accuracy, workflow, and knowledge of tools. In addition, training of clinicians in dealing with identified issues is lacking. Patients disclose more to and prefer computerized screening. An online clinical process support system (CHADIS) shows promise in addressing these issues.

Summary

Use of a comprehensive panel of online pre-visit screens; linked decision support to provide moment-of-care training; and post-visit activities and resources for patient-specific education, monitoring, and care coordination is an efficient way to make the entire process of screening and follow-up care feasible in primary care. CHADIS fulfills these requirements and provides Maintenance of Certification credit to physicians as well as added income for screening efforts.

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References

  1. 1.

    Basch E. Patient-reported outcomes—harnessing patients’ voices to improve clinical care. N Engl J Med. 2017;376:105–8. https://doi.org/10.1056/NEJMp1611252.

    Article  PubMed  Google Scholar 

  2. 2.

    Rotenstein LS, Huckman RS, Wagle NW. Making patients and doctors happier—the potential of patient-reported outcomes. N Engl J Med. 2017;377(14):1309–12.

    Article  PubMed  Google Scholar 

  3. 3.

    Bitsko RH, Holbrook JR, Robinson LR, et al. Health care, family, and community factors associated with mental, behavioral, and developmental disorders in early childhood—United States, 2011–2012. MMWR Morb Mortal Wkly Rep. 2016;65:221–6. 10.15585/mmwr.mm6509a1.

    Article  PubMed  Google Scholar 

  4. 4.

    Sturner RA, Granger RH, Klatskin EH, Ferholt JB. The routine “well child” examination: a study of its value in the discovery of significant psychological problems. Clin Pediatr. 1980;19(4):251–60. https://doi.org/10.1177/000992288001900403.

    CAS  Article  Google Scholar 

  5. 5.

    Ginsburg S, Foster S, Santoro K, Schoeman J and Chockley N. Strategies to support the integration of mental health into pediatric primary care. National Institute for Health Care Management. 2009.

  6. 6.

    American Academy of Pediatrics. Appendix S4: the case for routine mental health screening. Pediatrics. 2010;125(Supplement 3):S133–9.

    Article  Google Scholar 

  7. 7.

    Costello EJ, Edelbrock CS. Detection of psychiatric disorders in pediatric primary care: a preliminary report. J Am Acad Child Psychiatry. 1985;24(6):771–4.

    CAS  Article  PubMed  Google Scholar 

  8. 8.

    Costello EJ. Primary care pediatrics and child psychopathology: a review of diagnostic, treatment, and referral practices. Pediatrics. 1986;78(6):1044–51.

    CAS  PubMed  Google Scholar 

  9. 9.

    Costello EJ, Burns BJ, Costello AJ, Edelbrock C, Dulcan M, Brent D. Service utilization and psychiatric diagnosis in pediatric primary care: the role of the gatekeeper. Pediatrics. 1988;82(3):435–41.

    CAS  PubMed  Google Scholar 

  10. 10.

    Costello EJ, Costello AJ, Edelbrock C, Burns BJ, Dulcan MK, Brent D, et al. Psychiatric disorders in pediatric primary care: prevalence and risk factors. Arch Gen Psychiatry. 1988;45(12):1107–16.

    CAS  Article  PubMed  Google Scholar 

  11. 11.

    Lavigne JV, Binns HJ, Christoffel KK, Rosenbaum D, Arend R, Smith K, et al. Behavioral and emotional problems among preschool children in pediatric primary care: prevalence and pediatricians’ recognition. Pediatrics. 1993;91(3):649–55.

    CAS  PubMed  Google Scholar 

  12. 12.

    Horwitz SM, Kelleher KJ, Stein RE, Storfer-Isser A, Youngstrom EA, Park ER, et al. Barriers to the identification and management of psychosocial issues in children and maternal depression. Pediatrics. 2007;119(1):e208–18.

    Article  PubMed  Google Scholar 

  13. 13.

    Frodl TS, Koutsouleris N, Bottlender R, Born C, Jäger M, Scupin I, et al. Depression-related variation in brain morphology over 3 years: effects of stress? Arch Gen Psychiatry. 2008;65(10):1156–65.

    Article  PubMed  Google Scholar 

  14. 14.

    Edwards J, Maude D, McGorry PD, Harrigan SM, Cocks JT. Prolonged recovery in first-episode psychosis. The British journal of psychiatry. 1998.

  15. 15.

    Johnson CP, Meyers SM. Identification and evaluation of children with autism spectrum disorders. Pediatrics. 2007;120(5):1183. https://doi.org/10.1542/peds.2007-2361. originally published online October 29, 2007

    Article  PubMed  Google Scholar 

  16. 16.

    Belamarich PF, Gandica R, Stein RE, Racine AD. Drowning in a sea of advice: pediatricians and American Academy of Pediatrics policy statements. Pediatrics. 2006;118(4):e964–78.

    Article  PubMed  Google Scholar 

  17. 17.

    Hogan MF. New freedom commission report: the president’s new freedom commission: recommendations to transform mental health care in America. Psychiatr Serv. 2003;54(11):1467–74.

    Article  PubMed  Google Scholar 

  18. 18.

    Adang RP, Vismans FJ, Ambergen AW, Talmon JL, Hasman A, Flendrig JA. Evaluation of computerised questionnaires designed for patients referred for gastrointestinal endoscopy. Int J Biomed Comput. 1991;29(1):31–44.

    CAS  Article  PubMed  Google Scholar 

  19. 19.

    Lucas RW, Mullin PJ, Luna CB, McInroy DC. Psychiatrists and a computer as interrogators of patients with alcohol-related illnesses: a comparison. Br J Psychiatry. 1977;131(2):160–7.

    CAS  Article  PubMed  Google Scholar 

  20. 20.

    Katz LM, Cumming PD, Wallace EL, Abrams PS. Audiovisual touch-screen computer-assisted self-interviewing for donor health histories: results from two years experience with the system. Transfusion. 2005;45(2):171–80.

    Article  PubMed  Google Scholar 

  21. 21.

    Hewett PC, Mensch BS, Erulkar AS. Consistency in the reporting of sexual behaviour by adolescent girls in Kenya: a comparison of interviewing methods. Sex Transm Infect. 2004;80(suppl 2):ii43–8.

    PubMed Central  PubMed  Google Scholar 

  22. 22.

    Millstein SG, Irwin CE. Acceptability of computer-acquired sexual histories in adolescent girls. J Pediatr. 1983;103(5):815–9.

    CAS  Article  PubMed  Google Scholar 

  23. 23.

    Paperny DM, Aono JY, Lehman RM, Hammar SL, Risser J. Computer-assisted detection and intervention in adolescent high-risk health behaviors. J Pediatr. 1990;116(3):456–62.

    CAS  Article  PubMed  Google Scholar 

  24. 24.

    Sturner, R. A., Howard, B. J., Garver, L., Schneider, S. Morrel, T. Comparing alternative modalities for pre-visit screening for different demographic groups presented at the Pediatric Academic Societies annual meeting, Denver, CO., May, 2011.

  25. 25.

    Kemper K, Barkin SL, Kousky R. Gaps in psychosocial screening in a continuity clinic. Abstract no. 2019. Pediatr Res. 2004.

  26. 26.

    Bergman DA, Beck A, Rahm AK. The use of internet-based technology to tailor well-child care encounters. Pediatrics. 2009;124(1):E37–e43.

    Article  PubMed  Google Scholar 

  27. 27.

    Howard BJ, Sturner RA, Morrel T, Nail J and Bergmann P. An online tool for documenting DSM-5 and DSM-PC criteria for ADHD and co-morbid conditions. Presented at Soc. for Dev. Beh. Pediatrics. Cleveland, OH. 2017.

  28. 28.

    Wolraich M. Diagnostic and statistical manual for primary care (DSM-PC): child and adolescent version. Elk Grove Village: American Academy of Pediatrics; 1996.

    Google Scholar 

  29. 29.

    American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fifth edition. Arlington: American Psychiatric Association; 2013.

    Book  Google Scholar 

  30. 30.

    Achenbach TM, Rescorla LA. Manual for the ASEBA school-age forms & profiles. Burlington: University of Vermont, Research Center for Children, Youth, & Families; 2001.

    Google Scholar 

  31. 31.

    Sturner RA, Albus K, Thomas J, Howard BJ. A proposed adaptation of DC: 0-3 for primary care, developmental research and prevention of mental disorders. Infant Mental Health J. 2007;28(1):1–11.

    Article  Google Scholar 

  32. 32.

    ZERO TO THREE. Diagnostic classification of mental health and developmental disorders in infancy and early childhood, (rev. ed.). Washington, DC: ZERO TO THREE Press; 2005.

    Google Scholar 

  33. 33.

    American Academy of Pediatrics. Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011;128(5):1007–22.

    Article  Google Scholar 

  34. 34.

    Wolraich ML, Bard DE, Stein MT, Rushton JL, O’Connor KG. Pediatricians’ attitudes and practices on ADHD before and after the development of ADHD pediatric practice guidelines. J Att Dis. 2010;13(6):563–72.

    Article  Google Scholar 

  35. 35.

    American Academy of Pediatrics Committee on Practice and Ambulatory Medicine and Bright Futures Periodicity Schedule Workgroup. Recommendations for preventive pediatric health care. Pediatrics. 2016;137(1):1–3.

    Google Scholar 

  36. 36.

    Okelo S, Riekert KA, Eakin M, Collaco JM, McGrath-Morrow SA, Lee G, et al. Symptom trajectory, burden and risk as valid measures of asthma disease activity using the pediatric asthma control and communication instrument (PACCI). Am J Respir Crit Care Med. 2010;May 1;181(1_MeetingAbstracts):A5803.

    Google Scholar 

  37. 37.

    Howard BJ, Sturner R, Okelo S, Vullo GC, Berger, M, Bergmann P. Uncovering persistent asthma in health supervision visits presented at the Pediatric Academic Societies Meeting, 2017.

  38. 38.

    Knight JR, Shrier LA, Bravender TD, et al. A new brief screen for substance abuse. Arch Pediatr Adolesc Med. 1999;153(6):591–6.

    CAS  Article  PubMed  Google Scholar 

  39. 39.

    Scheeringa MS, Haslett N. The reliability and criterion validity of the Diagnostic Infant and Preschool Assessment: a new diagnostic instrument for young children. Child Psychiatry Hum Dev. 2010;41(3):299–312.

    Article  PubMed Central  PubMed  Google Scholar 

  40. 40.

    Kleinman JM, Robins DL, Ventola PE, et al. The modified checklist for autism in toddlers: a follow-up study investigating the early detection of autism spectrum disorders. J Autism Dev Disord. 2008;38(5):827–39. https://doi.org/10.1007/s10803-007-0450-9.

    Article  PubMed Central  PubMed  Google Scholar 

  41. 41.

    Sturner R, Howard B, Bergmann P, et al. Autism screening with online decision support by primary care pediatricians aided by M-CHAT/F. Pediatrics. 2016;138(3):e20153036. https://doi.org/10.1542/peds.2015-3036.

    Article  PubMed Central  PubMed  Google Scholar 

  42. 42.

    Committee on Quality of Health Care in America, Institute of Medicine Crossing the Quality Chasm. A new health system for the 21st century. Washington, DC: National Academies Press; 2001.

    Google Scholar 

  43. 43.

    Barry MJ, Edgman-Levitan S. Shared decision making—the pinnacle of patient-centered care. N Engl J Med. 2012;366:780–1. https://doi.org/10.1056/NEJMp1109283.

    CAS  Article  PubMed  Google Scholar 

  44. 44.

    McGoron L, Sturner R, Howard B, Barry TD, Seymour K, Tomeny TS, et al. Parents’ goals for ADHD care in a clinical pediatric sample. Clin Pediatr. 2014;53(10):949–59. https://doi.org/10.1177/0009922814543323.

    Article  Google Scholar 

  45. 45.

    Wolraich ML, Hannah JN, Pinnock TY, et al. Comparison of diagnostic criteria for attention-deficit hyperactivity disorder in a county-wide sample. J Am Acad Child Adolesc Psychiatry. 1996;35:319–24.

    CAS  Article  PubMed  Google Scholar 

  46. 46.

    Wolraich ML, Visser SN, Bard D, Cuffe S, Neas B, Geryk LL, Doffing M, Bottai M, Abramowitz AJ, Beck J R, Holbrook JR and Danielson M. The prevalence of ADHD: its diagnosis and treatment in four school districts across two states. J of Attention Disorders. 2012.

  47. 47.

    Miller WR, Rollnick S. Motivational Interviewing, Third Edition: Helping People Change/Edition 3. New York: The Guilford Press; 2012.

    Google Scholar 

  48. 48.

    http://www.lungtropolis.com/lungtropolis/accounts/login/ accessed Oct. 2017.

  49. 49.

    Jellinek MS, Murphy JM, Little M, Pagano ME, Comer DM, Kelleher KJ. Checklist (PSC) to screen for psychosocial problems in pediatric primary care: a national feasibility study. Arch Pediatr Adolesc Med. 1999;153(3):254–60.

    CAS  Article  PubMed Central  PubMed  Google Scholar 

  50. 50.

    Goodman R. Psychometric properties of the strengths and difficulties questionnaire. J Am Acad Child Adolesc Psychiatry. 2001;40(11):1337–45.

    CAS  Article  PubMed  Google Scholar 

  51. 51.

    Murphy JM, Bergmann P, Chiang C, et al. The PSC-17: subscale scores, reliability, and factor structure in a new national sample. Pediatrics. 2016;138(3):e20160038. https://doi.org/10.1542/peds.2016-0038.

    Article  PubMed Central  PubMed  Google Scholar 

  52. 52.

    Kroenke K, Spitzer R, Williams J. The PHQ-9: validity of a brief depression severity measure. Gen Intern Med. 2001;16:606–13.

    CAS  Article  Google Scholar 

  53. 53.

    Pandey J, Verbalis A, Robins DL, Boorstein H, Klin A, Babitz T, et al. Screening for autism in older and younger toddlers with the Modified Checklist for Autism in Toddlers. Autism. 2008;12(5):513–35. https://doi.org/10.1177/1362361308094503.

    Article  PubMed  Google Scholar 

  54. 54.

    Sturner R, Howard B, Bergmann P, Stewart L, Afarian TE. Comparison of autism screening in younger and older toddlers. J Autism Dev Disord. 2017; https://doi.org/10.1007/s10803-017-3230-1.

  55. 55.

    Ozonoff S, Heung K, Byrd R, Hansen R, Hertz-Picciotto I. The onset of autism: patterns of symptom emergence in the first years of life. Autism Res. 2008;1(6):320–8. https://doi.org/10.1002/aur.53.

    Article  PubMed Central  PubMed  Google Scholar 

  56. 56.

    Sturner R, Howard B, Bergmann P, Bet K, Stewart L, Williams R. Autism screening at the 18 month visit—dimensional vs. categorical approaches of alternative tools, presented at the Pediatric Academic Societies Meeting, 2017.

  57. 57.

    Sturner R, Howard B, Bergmann P, et al. Accurate autism screening at the 18-month well-child visit requires different strategies than at 24 months. J Autism Dev Disord. 2017; https://doi.org/10.1007/s10803-017-3231-020.

  58. 58.

    https://ushik.ahrq.gov/mdr/static_files/portals/cehrf/documents/HL7/2015PL/5_5_Final_Rec_Rpt_ChildrenEHRFormat_Unabridged.pdf?enableAsynchronousLoading=true accessed October 1, 2017.

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Correspondence to Barbara J. Howard.

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Conflict of Interest

The authors declare that they have a conflict of interest as employee (Howard) and consultant (Sturner) to the distributor of CHADIS (total Child Health), conflicts have been managed by IRB's for all research conducted.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors without IRB approval.

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This article is part of the Topical Collection on Screening

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Howard, B.J., Sturner, R. Use of an Online Clinical Process Support System as an Aid to Identification and Management of Developmental and Mental Health Problems. Curr Dev Disord Rep 4, 108–117 (2017). https://doi.org/10.1007/s40474-017-0124-z

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Keywords

  • Developmental screening
  • Pediatrics
  • Mental health screening
  • Clinical decision support
  • Care coordination
  • Maintenance of Certification