Table 1 Themes, ideas, and barriers from the innovation tournament

Patient Education

4

“Make sure there is information concerning depression. Offer incentives for patients. Give some example of why people are depressed”

“Not knowing how to get help, not wanting help”

“In addition to wraparound education on reducing stigma of depression and normalizing it as a mental health condition that can change over time, particularly with appropriate therapy/ resources, we could screen for depression using a “mood meter,” or some sort of “tool”, either a separate device or integrated onto screen, that gives brief explanation as to why we ask about mood state, then asks ‘over the last 2 weeks, I’ve been feeling “content / stressed / down/ depressed” etc. Each mood state gets its own color. If one selects, “depressed/down/hopeless” - the screen/ “meter” could light up a specific color, i.e., green or purple, and stay that color until the PCP arrives in the room. The PCP will see the very evident signal, and can start a conversation acknowledging mental health - even if to say, “it looks like the last 2 weeks have been going well for you! Great to hear.” Then move on with visit... obviously if light is “depression” signal, then PCP knows very clearly they need to follow up w/ [the PHQ]-9.”

“It gets overlooked because there is no standardized “checklist” or hard stop that ensures it gets done at every visit. There has been provider push back and gate keeping around when depression screening should be done, i.e. lack of recognition and prioritization despite evidence of benefit, and again no standardized expectation to perform and operationalize at the local level. We also need a greater focus on patient-centered efforts to explain why we are asking about depression on the delivery side as it may seem intrusive or confusing as to why we are seemingly “all of a sudden” more interested in if they’re depressed or not. I can imagine that this may feel suspect without a context.”

“I believe the office should set a group/days aside in the office for depression/anxiety. So many people in the world are going through these issues alone.”

“Being afraid to speak up. That’s why with a group you can physically see and hear from real people that are suffering from the same issues. Also physicians do not have the time to access a depression visit and a sick visit.”

“I don’t know if this idea will increase depression screening but I do think it has the potential to improve overall quality of care. I believe our current process, as it has been rolled out in my practice, is flawed. I believe it leads to inaccurate assessments and negatively impacts other aspects of the MAs rooming role including accurate BP [blood pressure] assessment. I believe this is a key aspect of what a provider should do with a patient, but we can think of prompts to avoid missing an opportunity when the agenda may overwhelm this issue. This could include simple signage that states something like – “Feeling blue? Talk to your provider.” “Feeling blue/sad? Please complete this form and talk to your provider.” The signs/form could be at the front desk, in the MA rooms or in the exam rooms. This is similar to a project I did several years go around smoking cessation that I think increased conversations but did not slow flow or lead to negative experiences for patients and our MAs.”

“The PHQ-9 is meant to be self administered. The MAs are ill-trained to do this effectively. Asking these questions while taking BP [blood pressure] negatively impacts both of these tasks. Depression needs to be considered at every visit and not based on some annual schedule. We are too wrapped up in process vs providing quality care.”

Reframe

8

“Change wording of questions & separate answers.”

“The way questions are being asked (feeling down, depressed or helpless). There’s no separation (they might feel down, but not depressed or helpless or vice or versa)”

“Breaking down the questions in the PHQ-2. Change it to: “Have you been thinking about something that happened in your past recently that has been depressing?” This is because most people don’t relate it to as depression, but they are still thinking about things that make them sad.”

“The current wording of the PHQ-2 just doesn’t make sense to the patients. Patients will often say no to this question. But, if you explore more and ask them to talk more. The question is too long or the wording doesn’t make sense.”

“I think that some of the questions that are currently on our depression screening can be confusing for the patient in order for them to respond appropriately. Clearer questions that are less intrusive on the surface could be beneficial.”

“Patients don’t always take these questions seriously and are just trying to get us out of the room in order to see their provider.”

“How have you been feeling lately? Any feelings of being down or little interest?”

“People get really offended. I think it’s important for them to feel important and cared about. Some people take it that way or some people blow me off, like, [they say] “No,” with a face that you can almost feel like there is something they are not telling us. I sometimes feel like I want to say, “Are you sure? We have resources,” but I don’t want to be pushy if they say no. I think there should be more follow-up questions, something to make them feel like they need to speak up because it’s everyday they could be feeling like that and are almost hating life. I would hate for someone to not speak up and feel better.”

“Maybe we shouldn’t limit the screening to just over the last 2 weeks. Depression isn’t always constant. Sometimes depression comes and goes, and 2 weeks is not a long enough time to determine that.”

“I’m not sure of any barriers but the procedure here at [XXX], the medical assistant goes over the health screening for every patient during triage. It covers fall risk, abuse, weight loss, advanced directives and depression screening. If they screen positive for depression we mention in the chief complaint “depression” and in the comments, we write “PHQ9” so once the physician takes over they will know to continue the depression screening.”

“I would consider talking to the patient before asking the questions to see what the patient is going through in their life then ask the 2 questions pertaining to depression”

“The questions: Everyday, more than half the days and several days. Patient are sometimes confused about the days. The questions should be worded differently to accommodate the patients who are depressed but do not want to talk about it. After screening my patients, I ask about depression every visit because in my opinion I have a few that may slip through the cracks and the questions sometimes does not go across well, so I try to identify what’s going on with the patient an then ask the questions again if they are confused and state they are depressed; I ask them, if anything is going on in their life within the last 2 weeks that they may want to talk about that might cause them to have some kind of depression”

“I think sometimes patients are reluctant to admit they may have depression, whether it is a cultural problem. Trying to make the patient feel comfortable during their visit so they admit there is an issue.”

“As above [barrier listed in idea]”

“Get to know your patient, I think that all physicians should know their patients, and be able to identify if something major has changed in their lives, just by looking at them or noticing a big change in their weight, blood pressure or any life-changing events. My experience is when I go to the doctor, the assistants are not that approachable and I do not feel 100% comfortable talking to them about anything personal such as, depression, suicide, or abuse. My idea is for the physician to take 5 min to ask these questions themselves, so they can get a better understanding of what the patient is actually going through, I feel much better talking to my physician about suicidal thoughts, abuse from a loved one, or even depression, I don’t want no one going around looking at me different, I know there is HIPAA, but really who actually follows HIPAA when it’s someone you work with.”

“They seem reluctant to talk to the Medical Assistants, [patients would] rather speak to a nurse/or the doctor. There is not enough eye contact. The first question is too broad of a question? Do you have little interest or pleasure of doing things? Patients get a little taken. Patients think that some questions are weird, like ‘Do you have trouble dressing?’”

Self-report

12

“Each PSR holds a smart tablet and opens a bookmarked PHQ-2 screen and the patient logs into MPM [MyPennMedicine] during check-in to complete the 2 questions. If negative - a pop-up to let the patient know the result is negative and some evidence-based mental wellness practices like mindfulness-based stress reduction and regular exercise. If positive - a pop-up to inform the patient, recommend the patient tell the provider, offer general resources. If positive - a notification goes to the provider via HCM tab (or other location readily available to the provider) and telephone encounter. The patient hands the tablet back to the PSR, who resets the form (logs the patient out). Next patient checks in - rinse, wash, repeat. If the patient is not on MPM, then it’s a good opportunity to encourage signing up and the tablet could have a second MPM signup bookmark, which would increase the use of MPM.”

“The current state of our practice is to have MA’s provide the screen during check-in. This adds to MA workflow and can distract from other check-in needs.”

“Patients could complete screening for depression on iPads while they wait to be called back for their appointment. This way it would be done for most patients before they even get into the room. Moderate or severe scores could trigger automatic referral to PIC to take the PCP out of the equation.”

“Time. Visits are limited and there is way too much to cover as it is.”

“I think that we should just avoid a PHQ-2 altogether and hand the patient a PHQ-9 with check-in forms.”

“Sometimes the patient would like to explain why they feel the way they feel about every PHQ question which may take up time. We are not properly trained to handle certain scenarios when it comes to comforting the patient.”

“Texting how you are feeling when you are feeling down or depressed to your primary care office or BH. Staff will respond back with a form screening questionnaire, based on answers, referrals are made to primary care provider, BH or crisis center is needed”

“Patients not answering questions honestly. (questions are asked by medical assistants and some patient may be embarrassed to really disclose how they are feeling)”

“As a PSA for 24 years, I see over 140 patients in our practice daily. Sitting on the front line, I encountered some patients with depressive disorder, difficulty expressing how they feel on a daily basis, I try to comfort and support patients as much as I can. I inform them we care and want to help. I sometimes find myself tearing up listening to the stories they tell but at the same time, trying to stay calm and professional and to provide the assistance they may need. My idea would be to help our patients the best we can, to go above and beyond the call of duty. Being that the patients may not be comfortable, afraid to open up, we can create a short form that can be attached to the pre- visit summary. We print a pre-visit summary for each patient on a daily basis. This form can provide questions that may help us to get the best care. Patients can then give this form to our Medical Assistance to review. if patients are in urgent need of help, we can give the form to our CCBH worker.”

“Patients may feel uncomfortable talking about their issue at the front desk, patients dealing with something so difficult may have a hard time trusting someone not knowing how this person may react to their situation, its very scary to share something so personal. We have an open office filled with a great deal of patients daily. So it is a little uncomfortable opening up. [XXX] is our practice CCBH worker, [XXX] is our Social worker, they are very involved with our patients. Our patients feel comfortable with [XXX] and [XXX], these patients are escorted to a private area in the office to get the help needed. A short form attached to our pre-visit summary may be more comfortable and private for patients to document how they feel without someone knowing or hearing their current situation. This way, the patient can be pulled away from the front office to a secluded area in the office without anyone knowing. No patient should have to deal with this alone.”

“I think that if the patients are allowed to answer the PHQ-2 questions on their own they would be more receptive when it comes to those questions”

“From my experience, I feel that the patients do not always answer the PHQ-2 questions honestly and I think that this is because there is such a frown upon depression.”

“Patient could answer these questions in the privacy of their homes, workplaces, or settings. These questions can be populated into the patients’ chart prior to office visit, which makes the questions more accurate. The answers can be more accurate when answered by the patient. Patients are very hesitant to answer these questions when asked face to face. By offering this questionnaire in the online check-in process it will ensure completion.”

“Time is the biggest factor for screening patients for depression. By offering this feature, online check-in process cuts the time of triage by a great amount.”

“Give patient access to Mychart either by iPad or computer while to enter answers to depression screening questions. This would also be a good way to ask about domestic violence, have patients check their med list and list their complaints in review of systems format etc. Offer a small incentive to patients for completing the screening questions such as a Starbucks gift card or a pen”

“Time and patient’s reluctance to answer questions with the medical assistant”

“When I went to see a doctor at another institution 8 years ago, I was handed an iPad that was loaded by the check-in clerk with surveys and questionnaires that were selected based on the doctor I was seeing; my reason for visit; and my demographics including age and gender. By the time I saw the doctor, all that information was in the EHR and available for his use using a simple Smartphrase. The same occurs at CHOP when I visit a doctor with my child. Both sites use Epic. It is well established that patients are more likely to be forthcoming about personal issues with a tablet or kiosk than they are with a staff member (see, for example, https://www.annemergmed.com/article/S0196-0644(02)00080-X/abstract). My big idea is to make the provision of tablets a must-have element of EHR-based practice in every outpatient practice in the health system, and to have a PHQ-2 be part of the pre-visit survey completed on a tablet in the waiting room for patients due for screening.”

“The single greatest barrier to effective screening is the workflow that has the questions asked verbally by rushed and inexpert medical assistants, and recorded on paper for transcription by busy clinicians. There is no workflow that uses paper that works well in our practice, and this is a prime example. The other barrier is a philosophy that tablets are somehow a luxury for affluent (procedure-based, RVU-dense) practices, and not a must-have element of an EHR. Tablets should be as much a part of the IT outlay for an outpatient practices as keyboards, printers, and up to date computers. When we ask practices to pay for elements of the EHR out of revenues, it conveys a message that a complete EHR is only something you can afford if you do procedures. This leads providers to eschew the labor-intensive paper-based parts of the visit including depression screening.”

“Send patient a MPM [MyPennMedicine] message 1-2 weeks before their appointment asking them to complete to save time at their appointment. This would allow them to complete in private without being rushed.”

“I worry that the screening done by MAs is so impersonal and rushed that patients don’t answer honestly, not unusual for patients coming in for depression to have 0/0 on PHQ-2.”

“Send a pre-visit (within 24-48 h of the visit) message to patients via MPM [MyPennMedicine] enabled and showing no PHQ-2 screening in the previous year, similar to the plan for social determinants of health. They could complete the Smart forms before the visit and if positive could be flagged in the chart.”

“So far, I think our practice has really improved our screening of patients with the MA’s asking the PHQ-2 with vitals. However, there is a barrier that many patients are not being handed a PHQ-9 and, if they are, the PHQ-9 s are being scanned in instead of manually entered in PennChart [Penn Medicine’s version of Epic©] to satisfy having completed the measure. Certainly, it is a barrier asking this question to patients who have a long-standing history of depression/mood disorder. Those patients should either receive a PHQ-9 or have a documented discussion of the diagnosis in the visit, but we lack a workflow to identify those patients unless they are known to provider they will be seeing. Another barrier is time. When we screen for depression and it is a new finding, it is important and takes up a lot of our 20 min of time with the patient. We would love having more behavioral health staff on site for assistance with this workflow.”

“Confidential survey for any and all patients to take prior to or during the wait for his/her provider. Survey will ask the same, if not more, detailed questions about whether or not they have felt depressed in the last 1-3 months. I’ve noticed that a lot of patients feel as though the 2-week screening does not help give their provider good insight on how they have been feeling overall. I feel this will also give the patient a sense of control and privacy. Some patients do not want to answer the questions when we, the medical assistants, ask because we are not “trained” or “do not have the skills and knowledge” to do so. Furthermore, I feel that this would give the patients who are unsure if they are experiencing depression or any other mental issue, a good idea of what signs and symptoms to look for in their daily lives...I would like them to be able to identify the difference between normal life stressors and extreme stressors that are prolonged, causing life disruptions.”

“Some patients do not want to answer the screening questions with anyone but the doctor because it is uncomfortable. Some patients state they do not need to answer the questions because they are receiving treatment elsewhere.”

Workflow changes

7

“I think it would be helpful for the medical assistants to be properly trained in asking the depression screening questions and how to properly respond to the patients who are currently going through depression.”

“A lot of the times the clinical staff is the first person to go over the depression screening with the patient and when a patient is feeling depressed and tries to discuss it with the clinical staff, I feel that the staff does not always know how to properly react toward that patient to comfort them or explain the process with the physician going over the next steps to help the patient. My fear is the patient tried to converse with the MA prior but the MA’s have such limited time with the patients when rooming and if the patient feels rushed or cut off by the time the physician comes in the patient may then feel closed off or shut the communication down since they couldn’t openly communicate with the Medical Assistant. I feel if there is a proper training for the clinical staff on communication with the patients for the depression screening both the patient and the medical assistant would feel more comfortable is asking the questions with a better understanding on how to react.”

“At the [XXX] clinic, RN/MA’s are scoring PQH-2 during the check-in process. This is a perfect time to do screening as patients often are just waiting for their physicians to arrive. However, as a resident doctor I didn’t realize this was being done or where to look for the score until I asked another colleague in the clinic. It would be helpful to 1) do this screening in other clinics if not already adapted and 2) spread awareness that i) this screening is now in place at our practice and ii) where to look for the PHQ-2 score in the electronic system. This can be done by sending a bulletin email to the providers in the practice.”

“No significant barriers currently.”

“I think the best way to increase screening is to actually remind the primary care provider to ask these two questions during the exam via a Best Practice Advisory flag once the chart is open and the patient is in the room. It should be a reminder only to complete the PHQ-2. If they want to, they can by-pass it but it may improve the number of patients screened if the primary care provider is aware that they do not need to directly address the results at the time of the appointment unless the appointment is for mental health purposes in which case the questionnaire is a moot point.”

“A provider believing that they will be forced to address the results at the current visit will create the perception that this screening tool is going to prolong the appointment and create further schedule delays.”

“I have created a visit tool for the Medical Assistants to use in our office. The Medical Assistants use this form to remind them to review all of the meaningful use/quality questions. If the patient has a positive PHQ-2 the Medical Assistant documents this on the Chief Complaint along with the reason for the visit. Example. Patient here for follow up of hypertension (positive PHQ-2) the physician then knows to complete the PHQ 9.”

“The practice was understaffed for an extended amount of time.”

“The idea would consist of asking all patients who are coming in for an annual exam or coming in with a set of chief complaints (insomnia, fatigue, sleep apnea, narcotic refill, back pain) the following question. “In the last 2 week have you noticed any change in your mood, be it worsening depression and anxiety”. If answered yes, this would prompt a PHQ2 or 9. One feature of this initiative would be the need for EPIC to capture this information as an adequate screen. This could simply be done by clicking a “yes/no” button that says. “I have screened this patient for depression.”

“There is often not sufficient time to do a full depression screen during a visit. Also, if depression is discovered, there is often not enough time to do a full psychosocial evaluation and discuss treatment. This often takes a full 30 min visit on it’s own and there are often other chronic health issues to discuss.”

“The PHQ-2 screening is a good starting point. This can be done by medical assistants just as vital signs are done. The problem is finding the information in the chart and knowing if it’s even there to find. It’s unclear at each practice if PHQ-2’s are already being done all the time, some of the time, or never. Most primary care doctors include vital signs in their note. Personally, I review the vital signs that are unloaded into my note as I am writing the note and during the visit. If the PHQ-2 was added to the vital sign portion so it would be uploaded with typical vital signs or if more physicians included PHQ-2 results to upload into the note, I think this would increase depression screening. If the MA’s would give patients who screened positive on PHQ-2, the full PHQ-9 and GAD-7 questionnaires, this would save significant time and be very helpful for the visit.”

“Time, remembering to do it on all patients, not knowing if it was already done by the MA and where that information is”

“Many barriers exist to screen adults for depression including the fact that many adults at risk for depression do not schedule or keep appointments for themselves. However, these adults may encounter primary care practices many times throughout the year when they present with family members including aging parents or young children. Pilot data across many primary care sites has demonstrated that screening mothers who attend well child visits is an effective platform to screen for depression and provide care for women at risk for depression. It is possible to build on this idea and extrapolate to other adults who present to primary care appointments with their spouses, partners or relatives. While not all family members will necessarily have their primary care within UPHS, a significant proportion will. Screening family members during routine primary care visits using a validated tool could close the gap in depression screening and improve care for patients and their families.”

“1. Limited time to address multitude of patient concerns 2. Workflow which does not effectively operationalize screening by non-providers 3. Absence of case management services within the practice”

1

No idea

“Barriers: Not enough time during visits. Way too much to address at each visit; screening often takes a back seat to active issues. No quick way to identify last time someone was screened.”