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