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Table 3 Rapid Prototyping Process for Tablets

From: A pilot study of participatory and rapid implementation approaches to increase depression screening in primary care

  

Day 1

Day 2

Day 3

Day 4

Day 5

Design Summary

Screening Location

Waiting Room

Exam Room

Waiting Room

Waiting Room

Waiting Room

Assigning the Questionnaire

The Patient Service Associate (PSA) assigned the patient the questionnaire at check-in and provided the research team with the patient codes after check-in. The PSA would signal to research team when a patient needed to be screened.

The PSA assigned the questionnaire to patients at check-in. PSA would signal when a patient needed to be screened. Research team received the patient codes ahead of the shift and input the codes in the tablet.

The PSA assigned the questionnaire at check-in. PSA would signal when a patient needed to be screened. Research team received the patient codes ahead of the shift and input the codes in the tablet.

The PSA assigned the questionnaire to patients the morning before the shift (well before check-in). The PSAs entered the patient code in the tablets before handing the tablets to patients.

The PSA assigned the questionnaire at check-in. The PSAs entered the patient code in the tablets before handing the tablets to patients.

Tablet Hand-off

Research team held onto tablets and approached patients with the tablet and took the tablet back from the patient.

Research team held onto the tablets. When the patient was called to the exam room we accompanied the patient and MA.

Research team held onto tablets and approached patients with the tablet and took the tablet back from the patient.

The PSAs gave patients the tablet at check-in. Patients were instructed to fill out the PHQ while in the waiting room and to bring back the tablet to the front desk as soon as they were finished.

The PSAs gave patients the tablet at check-in. Patients were instructed to fill out the PHQ while in the waiting room and to bring back the tablet to the front desk as soon as they were finished.

Administration Plan

Research team assisted patients if they had questions.

Research team assisted patients if they had questions.

Research team assisted patients if they had questions.

Patient self-administered the PHQ-2.

Patient self-administered the PHQ-2.

Follow-Up Plan

The plan was that if the patient screened positive, the Medical Assistant (MA) put down a red sheet of paper to notify physician.

The plan was that if the patient screened positive, the MA put down a red sheet of paper to notify physician.

The plan was that if the patient screened positive, the MA put down a red sheet of paper to notify physician.

The plan was that if the patient screened positive, the MA put down a red sheet of paper to notify physician.

The plan was that if the patient screened positive, the MA put down a red sheet of paper to notify physician

Screening Results

Tablet Administration

7 out of 8 patients completed the PHQ-2 on the tablet.

5 out of 7 patients completed the PHQ-2 on the tablet.

5 out of 8 patients completed the PHQ-2 on the tablet.

6 out of 7 patients completed the PHQ-2 on the tablet.

6 out of 6 patients completed the PHQ-2 on the tablet.

Verbal or Non-tablet Administration

1 patient was roomed early and completed the PHQ verbally in the exam room with the MA.

1 patient completed the screener verbally because the PSA forgot to assign the questionnaire. 1 patient did it verbally because the patient was blind.

1 patient was very frail and elderly and could not operate the tablet and therefore completed the PHQ-2 verbally with the MA. 2 patients were called into the exam room before the research team was able to administer the questionnaire and completed the PHQ-2 verbally with the MA.

1 patient had completed the questionnaire on MyPennMedicine prior to their visit because the PSA had assigned the questionnaire before the appointment.

No non-tablet administration.

Workflow Successes

Patient Perspective

4 out of 7 patients indicated that they liked answering questions on tablets and that they were easy to use.

4 out of 5 patients indicated that the tablet was acceptable and more confidential.

5 out of 5 patients who used the tablet indicated that they were easy to use and that they preferred self-report over the MA asking them questions.

6 out of the 6 patients who used the tablet indicated that tablets were easy to use and fast. All of the patients brought the tablet back to the front desk when they were finished. Patients reported no barriers to completing the questionnaires on the tablets.

5 out of the 6 patients who used the tablet indicated that they liked it.

Staff Perspective

PSAs said the process was fairly straightforward. They were initially confused about assigning the depression screening questionnaire (several processes and codes they needed to enter) but by the final patient, the time it took to assign the questionnaire decreased from as much as 5 min to less than 1 min.

The MA said that the process of completing the PHQ-2 in the exam room worked better than the waiting room because in the waiting room, patients don’t have privacy.

PSAs indicated that the process (assigning the questionnaire) was increasingly straightforward as long as they did not have to handle the tablets. They said the instructions were helpful and clear.

PSAs who had all participated in the pilot in previous shifts were now familiar with the workflow, with how to use the tablets, and how to introduce the study. PSAs also remembered to assign the questionnaire to all participants. The PSAs also handed the tablet to patients, so it was obvious which patients were the physician’s and who needed to be interviewed.

The MA indicated that the tablet process has been straightforward and cuts down on what they have to do, which is a benefit. They hoped that many other questions could be put on the tablet. PSAs described the final day of piloting as “smooth sailing” as they got accustomed to the process. They were surprised by how many patients remembered to return the tablets.

Clinician Perspective

Physician did not report noticeable changes.

Physician indicated that from their perspective, things have been “working great.”

Physician did not report noticeable changes.

Physician did not report noticeable changes.

Physician indicated that from their perspective, the tablet process has been smooth.

Workflow Challenges

Patient Perspective

2 of 7 patients appeared to be confused by the tablets and/or questions and required assistance. 1 patient took a long time (20 min) to complete the PHQ.

1 patient who had completed the PHQ-2 on the tablet had not authorized their responses and therefore, the responses were not submitted. 1 patient was blind, suggesting a need for a back-up plan. 1 patient voiced strongly disliking the tablet. Patients took a long time to complete the tablet from 2 to 12 min. 1 patient asked that we use disinfectant wipes.

3 patients could not answer the depression screener on the tablet.

1 patient reported wanting an option to fill out the questionnaire online ahead of their appointment. Another patient expressed worries about getting sick from touching the tablets.

1 patient voiced extreme dislike of the tablets and said that they preferred to talk to a person.

Staff Perspective

1 PSA indicated that it would be better to have the patient name, appointment. Time, and the CSN (identifying number) at the beginning of the rapid prototyping shift to assign before check-in.

PSAs expressed feeling overwhelmed, frustrated with the additional burden, and needing more explicit instructions and reminders to assign the patients the questionnaire.

PSAs expressed needing reminders to assign the questionnaires, because they sometimes forgot.

The 3 PSAs all expressed not liking the new workflow process, as it put more responsibility on their shoulders and was disruptive to the workflow. They said it was time-consuming and did not know what they would do if patients forgot to hand them back the tablets.

The MA expressed concerns about the scalability of the project. The MA indicated that for many elderly patients, tablets are infeasible, which means they would have to be screened by the MA anyway. The MA also said that if patients take long in the waiting area, this cuts down on the rooming time.

 

1 PSA said that it would be nice to have a short script she could follow in order to inform patients when they arrive regarding the tablet pilot.

1 PSA reported not understanding the rationale for depression screening and feeling that it was unclear why screening was a priority.

 

1 of the PSAs had been proactive to avoid delays in check-in and assigned the questionnaires to the physician’s patients ahead of time (the morning of the shift). This inadvertently assigned the questionnaire through the confidential patient portal. One patient saw that the questionnaire had been assigned to them via email and completed the PHQ-2 prior to check-in.

The 2 PSAs indicated that the tablet screening required more time and disrupted the workflow. The PSAs preferred that the questionnaires be administered before check-in (online, through the confidential patient portal).

    

Despite having disinfecting wipes, the PSAs reiterated concerns about illness (many sick patients were in the office).

 

Clinician Perspective

Physician had no constructive feedback this cycle.

The physician reported that the MA was placing the red paper down when the patient completed the PHQ-9 *not* when the patient scored positive on it. Physician said additional MA training was needed.

Physician indicated that despite additional training, the MA continued to place a red paper down even when the patient had not screened positive on the PHQ-9.

Physician had no constructive feedback this cycle.

Physician indicated that going forward suicide protocols were needed. In addition, physician felt it was important that the electronic health record had only place to enter PHQ data.

Technical and Workflow Challenges

One of the tablets did not work.

The other tablet was still being fixed, leaving the team with only one tablet.

Research team did not have a patient list with names, making it difficult to tell which patients should be screened.

 No technical or workflow challenges

No technical or workflow challenges 

 

Research team was stationed on the other side of the waiting room from the entrance and front desk. That made it difficult to identify patients for the questionnaire.

PSAs sometimes forgot to assign the questionnaire, and 1 PSA had not been trained in how to assign the questionnaire and, so, required additional training during a busy moment.

PSAs forgot to assign the questionnaires and had to be reminded.

  
 

Research team did not have the physician’s schedule ahead of time, so did not know which patients to look for or the code to enter in the tablet computer

In the exam room, the MA had to wait a long time for patients to complete the questionnaire, delaying the pre-visit vitals assessment. The MA still had to ask other questions to the patient and indicated that those questions should also be included in the tablet questionnaire.

   
 

The tablet only held a charge for ~ 3 h and needed to be plugged in.

Mid-rapid cycle prototyping shift, a new MA who had not been trained in the protocol saw the physician’s patients.

   

Summary of Changes to Test for Next Cycle

For Staff

Create a 3-sentence script for PSAs to say when handing tablets to the patients.

Refine the PSA script and provide more specific instructions (with screenshots) for PSAs

Attempt to have PSAs hand off the tablet and ask patients to return the tablet to the PSA. Ask PSAs to assign all eligible patients the PHQ questionnaire before the shift to reduce time at check-in.

Provide additional disinfecting wipes to PSAs per their request (beyond the ones already given to patients).

 No changes (last cycle).

  

Retrain MAs about protocol and provide laminated instruction sheet. Ensure that the MA is only putting the red paper down when the patient screens positive, not just when they complete the PHQ-9.

Retrain MAs about protocol. Ensure that the MA is only putting the red paper down when the patient screens positive, not just when they complete the PHQ-9.

  

Technical Changes

Station ourselves next to the front desk and near an electrical outlet for ease of charge and for easier access to see patients and to hand the tablet to the PSAs.

One patient suggested disinfectant wipes to wipe down the tablet because many patients are sick. Research team will bring disinfecting wipes next time for the tablets.

 No technical changes.

Revert to assigning the questionnaires at check-in to avoid patients completing the PHQ-2 at home through the confidential patient portal.

No technical changes (last cycle). 

 

Request the identifying number from the practice manager ahead of the shift so we can enter it in the tablet as soon as the patient checks in.

Research team will ask about the MA schedule to ensure that the MAs working during the next rapid prototyping cycle are trained.

   
 

Administer the patient questionnaire in the exam room.

Despite the privacy advantages of the exam room for the sake of time, administer the patient questionnaire in the waiting area.

   
   

Remind patients to authorize their responses when completing the PHQ-2 on the tablet.