| Although primary prevention strategies have | | | | multiple patients to be screened |
| great potential to improve health across the | | | | simultaneously, since there can be more than |
| general population in a cost effective way, | | | | one unit available in each practice.†|
| they appear relatively under-utilized. | | | | |
| | | | Why hand-held computers? |
| A good example is the provision of screening | | | | |
| and brief intervention for alcohol misuse in | | | | Using hand-held computers allows multiple |
| general practice (primary care). Several | | | | patients to be screened simultaneously, since |
| reviews and analyses have established that | | | | there can be more than one unit available in |
| brief interventions provided by primary care | | | | each practice. They ensure patient privacy |
| physicians can significantly reduce | | | | because the computer screen is not visible to |
| individuals' alcohol consumption. Despite | | | | anyone other than the current user. |
| this, detection of, and intervention for, | | | | |
| excessive drinking among primary care | | | | Another advantage of hand-held computers is |
| patients is known to be low, with primary | | | | that patients who are happy for their GP to |
| care physicians likely to provide advice only | | | | see their results can take the computer into |
| when patients' smoking or alcohol consumption | | | | their consultation with them. This provides |
| levels are high. | | | | GPs with the option of referring to the |
| | | | computer, which specifies the exact nature of |
| Previous analyses have investigated the | | | | the at-risk behaviour, after the patient's |
| apparent anomaly between evidence for | | | | presenting problem has been addressed. For |
| effectiveness and failure to implement | | | | example, GPs can access patients' on-screen |
| appropriate activities to reduce excessive | | | | feedback to ascertain if patients are |
| alcohol consumption. These have principally | | | | drinking in excess of recommended average |
| focused on two areas thought to be amenable | | | | weekly levels of consumption, as well as |
| to change: characteristics directly relevant | | | | binge or episodic consumption. They are also |
| to healthcare providers, such as their | | | | able to access specific advice given to |
| awareness of research evidence and the | | | | patients and can be prompted to provide |
| quality of their undergraduate and on-going | | | | additional intervention in the form of |
| training; and patient characteristics, such | | | | computer-assisted brief advice, perhaps |
| as their reluctance to disclose their risky | | | | complemented by a self-help booklet. Given |
| behaviours. | | | | individual consultations will vary enormously |
| | | | in terms of their scope and difficulty, |
| A third possibility, that has received | | | | making the availability of computer |
| relatively little critical attention, is the | | | | information optional means that the timing |
| feasibility of modifying the nature of health | | | | and extent to which the computer information |
| care consultations. In the parlance of | | | | is utilized is at the GPs' discretion. |
| systems research, this is akin to modifying | | | | |
| systems of work. The underlying premise is | | | | A third advantage of hand-held computers is |
| that regardless of the way prevention and | | | | that they have been demonstrated to be |
| early intervention is delivered, healthcare | | | | acceptable in obstetric and gynaecology |
| providers may be too busy to screen for risk | | | | clinics, with patients reporting they were |
| factors outside the purview of the immediate | | | | comfortable using them and preferred them to |
| consultation, and are unlikely to have time | | | | pen-and-paper surveys. |
| for adequate training in those areas not | | | | |
| perceived by them as essential to the | | | | Why in waiting rooms? |
| provision of high quality healthcare. | | | | |
| | | | Although average waiting times for GP |
| One novel method for potentially modifying | | | | consultations are unknown and are likely to |
| the nature of healthcare consultations is the | | | | vary at different times of the day, hand-held |
| integration of patient-driven computers into | | | | computers make more effective use of this |
| routine clinical care. This has two potential | | | | time by obtaining information about patients' |
| advantages: | | | | health and at-risk behaviours, in order to |
| | | | provide both GPs and patients with clinically |
| Hand held computers make relevant | | | | useful information. |
| information, tailored to individual patients, | | | | |
| available to practitioners at the time when | | | | Feasibility of using hand-held computers |
| it is likely to be most useful: during the | | | | |
| consultation. | | | | Recognizing that this technology represents a |
| | | | logical progression from current practice |
| Hand held computers facilitate in situ | | | | enhances the likely feasibility of hand-held |
| professional education: providers learn | | | | computers. Despite evidence that GPs' |
| preventive recommendations and guidelines in | | | | detection of health risk behaviours is |
| the context of a specific patient encounter; | | | | generally low, many GPs are already recording |
| they also learn how to provide | | | | this information in some form, and are being |
| evidenced-based interventions by being | | | | encouraged to do so through various incentive |
| prompted, by the computer, through | | | | schemes, including the GP contract system in |
| appropriate advice for each patient. As such, | | | | the UK and targeted payments in Australia. |
| this type of education capitalises on the | | | | Given governments in both the UK and |
| advantages offered by problem-based learning. | | | | Australia have encouraged GPs to move toward |
| | | | computer-based records and prescribing in |
| | | | recent years, the electronic transfer of data |
| Patient-driven computers in routine clinical | | | | from patient driven hand-helds to |
| care | | | | practice-based computers also appears |
| | | | logical. In this current context, the |
| How might hand held computers work in | | | | feasibility of hand-held computers could |
| practice? | | | | provide further efficiencies in both |
| | | | screening a greater proportion of patients |
| At present, the general system of a primary | | | | initially and, relatively seamlessly, |
| care consultation is that patients report to | | | | improving patient records, for minimal |
| the receptionist and then wait for their | | | | additional cost. |
| consultation. An alternative system would | | | | |
| have patients reporting to the receptionist | | | | The extent to which hand-held computers might |
| who would, on completion of existing | | | | achieve this promise depends, in part, on |
| procedures, provide them with a hand-held | | | | identifying why this technology might not be |
| computer. After answering screening questions | | | | widely adopted into routine clinical care. |
| and being provided with on-screen tailored | | | | Reasons may include: |
| feedback, patients could be asked if they | | | | |
| would like their general practitioner (GP) to | | | | a lack of patient waiting time; |
| see a summary of their results. If they say | | | | |
| yes, the computer would indicate that the | | | | poor understanding of the process by clinical |
| patient should take the hand-held computer | | | | staff; |
| with them into their consultation and if not, | | | | |
| to return it to the receptionist. | | | | a perceived lack of confidence in their |
| | | | ability to use computers; and |
| Why screen by computer? | | | | |
| | | | suspicion about how data may be used. |
| The use of patient-driven computers has | | | | |
| several advantages: | | | | Data on patient waiting times would be useful |
| | | | for determining how many risk factors can be |
| They improve the feasibility of screening a | | | | screened for, or specific questions asked, at |
| substantial proportion of GPs' patients by | | | | each patient visit. For example, patients |
| acknowledging GPs' time constraints and | | | | attending early in a consultation session may |
| facilitating screening and feedback | | | | have less time to complete screening |
| independently of GPs. | | | | questions because waiting times are likely to |
| | | | be shorter, relative to later in a |
| Evidence suggests data collected by computers | | | | consultation session. |
| is more reliable and valid than data | | | | |
| collected by other screening methods, results | | | | Successful implementation of this technology |
| in less missing data and is acceptable to | | | | also depends on the extent to which its use |
| patients. | | | | is sustainable. Sustainability could be |
| | | | optimized by screening for different risk |
| Computers minimize the possibility of errors | | | | factors on different patient visits, tracking |
| since responses are scored automatically. | | | | patients' progress on individual risk factors |
| | | | over time, screening for particular risk |
| The possibility of misinterpreting data is | | | | factors to coincide with national campaigns, |
| minimized by providing patients with instant | | | | utilizing a mechanism for quickly and simply |
| feedback tailored to their answers, including | | | | merging collected data with existing |
| recommendations for how they could modify | | | | electronic or paper-based GP records and |
| their behaviours. This optimizes the | | | | linking information to a database to prompt |
| usefulness and relevance to patients of the | | | | the mail-out of relevant self-help type |
| information collected. | | | | material or support computer-based brief |
| | | | interventions. |
| “Using hand-held computers allows | | | | |