Tailored Interactive Multimedia Computer Programs (IMCPs) in the Doctor’s Office: Activating Patients with Technology Anthony Jerant, MD Paul Duberstein,

Tailored Interactive Multimedia Tailored Interactive Multimedia Computer Programs (IMCPs) Computer Programs (IMCPs)

in the Doctor’s Office:in the Doctor’s Office:Activating Patients with TechnologyActivating Patients with Technology

Anthony Jerant, MDAnthony Jerant, MD

Paul Duberstein, PhDPaul Duberstein, PhDApril 8, 2010April 8, 2010

OverviewOverview Review the use of tailored IMCPs in doctors’ Review the use of tailored IMCPs in doctors’

offices to activate patients for behavior changeoffices to activate patients for behavior change

Discuss how health behavior and Discuss how health behavior and communication persuasion theories and communication persuasion theories and research can inform choice of tailoring variables research can inform choice of tailoring variables and creation of tailored activating messagesand creation of tailored activating messages

Consider practical/design issues that relate to Consider practical/design issues that relate to office-based deployment of tailored IMCPsoffice-based deployment of tailored IMCPs

OverviewOverview Illustrative example: NIMH-funded project Illustrative example: NIMH-funded project

(R01 MH079387 Kravitz)(R01 MH079387 Kravitz)

Develop and evaluate the effects of a Develop and evaluate the effects of a tailored IMCP aimed at screening for and tailored IMCP aimed at screening for and raising awareness of possible raising awareness of possible depressiondepression in primary care and, when appropriate, in primary care and, when appropriate, encouraging care seekingencouraging care seeking

Tailored IMCPs: Nuts and BoltsTailored IMCPs: Nuts and Bolts Core elements: Core elements:

Tailoring questionnaireTailoring questionnaire Tailoring algorithm and associated logicTailoring algorithm and associated logic Tailored message libraryTailored message library

Allow delivery of tailored information in Allow delivery of tailored information in real time, on the flyreal time, on the fly

Tailored messages can be provided in Tailored messages can be provided in form of text, audio, animation, videoform of text, audio, animation, video

Health-Related Tailored IMCPs:Health-Related Tailored IMCPs:What’s the Point?What’s the Point?

To encourage healthier (“more optimal”) patient To encourage healthier (“more optimal”) patient behaviors and, ultimately, improve health behaviors and, ultimately, improve health outcomesoutcomes

Seek to activate patients for change, rather than Seek to activate patients for change, rather than being focused on building knowledgebeing focused on building knowledge PsychologicalPsychological tailoring tailoring Different than either traditional leaflets or decision Different than either traditional leaflets or decision

aidsaids


Different definitions of activation exist Different definitions of activation exist (Greenfield et al, Hibbard et al, etc).(Greenfield et al, Hibbard et al, etc).

Ours focuses on a patient’s ability to Ours focuses on a patient’s ability to optimize optimize a a specificspecific health behavior health behavior


Activated patients are: Activated patients are: “…“…primed with the requisite knowledge and in primed with the requisite knowledge and in

possession of the necessary skills, resources, possession of the necessary skills, resources, and motivation to pursue an optimal health and motivation to pursue an optimal health behavior (that is, a behavior associated with behavior (that is, a behavior associated with better health outcomes).”better health outcomes).”

Tailored IMCPs and ActivationTailored IMCPs and Activation

May foster patient activation in a number May foster patient activation in a number of waysof ways Via tailoring to psychological and other Via tailoring to psychological and other

variablesvariables By mitigating barriers to optimal careBy mitigating barriers to optimal care

• Language Language • Time constraints in doctor visitsTime constraints in doctor visits• Physician factors (e.g. interviewing skills, social Physician factors (e.g. interviewing skills, social

distance)distance)

Goals of Psychological TailoringGoals of Psychological Tailoring

Goal 1: Maximize perceived salience or “fit” Goal 1: Maximize perceived salience or “fit” of information to the individualof information to the individual

Particularly relevant when information is Particularly relevant when information is tailored to largely immutable characteristicstailored to largely immutable characteristics Examples: personality traits, information Examples: personality traits, information

processing style, processing style, illness explanatory modelillness explanatory model

When discussing treatment of depression with the doctor today, it may help to know more about the causes of depression.

Earlier, you said that, in your opinion, important cause(s) of depression are: • A chemical imbalance in the brain • Feeling life is meaningless, lacks purpose, or is spiritually empty• Problems in relationships with others

We respect your opinion.

Studies have found that there is no one cause of depression. Rather, it can affect anyone, and seems to result from a combination of things. However, exactly how important each of these things is in causing depression varies a lot from person to person.

This is why talking with a qualified health care provider, such as a primary care doctor, is recommended to properly evaluate depression. It is also why there is no one treatment for depression that is best for everyone.Instead, treatment of depression must be tailored to best meet each person’s needs.

To learn more about causes of depression, please touch the “More Information” button.

When you are ready to move on, please touch the “Next” button.


Goal 2: Favorably influence (“bolster”) the status Goal 2: Favorably influence (“bolster”) the status of mutable psychological characteristics that of mutable psychological characteristics that mediate health behaviormediate health behavior

Examples:Examples: Self-efficacySelf-efficacy Perceived barriersPerceived barriers Stage of readinessStage of readiness Regulatory fitRegulatory fit

Tailoring to Self-EfficacyTailoring to Self-Efficacy Self-efficacy: confidence in ability to take Self-efficacy: confidence in ability to take

steps toward a behavior change goalsteps toward a behavior change goal

Task specificTask specific

Influenced by: Influenced by: Previous performance accomplishmentsPrevious performance accomplishments Vicarious experiencesVicarious experiences Verbal persuasionVerbal persuasion

Tailoring to Self-EfficacyTailoring to Self-Efficacy

Can also be bolstered by characterizing Can also be bolstered by characterizing and providing salient suggestions for and providing salient suggestions for overcoming perceived barriers to overcoming perceived barriers to implementing a behaviorimplementing a behavior

Video clip


Often, as in the depression tailored IMCP, Often, as in the depression tailored IMCP, both goals 1 and 2 are pursuedboth goals 1 and 2 are pursued

Overcoming Language BarriersOvercoming Language Barriers

Tailored IMCPs can be created in multiple Tailored IMCPs can be created in multiple languageslanguages

User selects preferred language versionUser selects preferred language version

Overcoming Time ConstraintsOvercoming Time Constraints

Time constraints in doctors’ offices are Time constraints in doctors’ offices are severesevere

Mental health issues take time to discussMental health issues take time to discuss

Offering tailored IMCPs for use by patients Offering tailored IMCPs for use by patients in the doctor’s office before visits can in the doctor’s office before visits can effectively expand the physician-patient effectively expand the physician-patient encounter in space and time encounter in space and time

Buffering Adverse Physician EffectsBuffering Adverse Physician Effects

Tailored IMCPs deployed in doctors’ Tailored IMCPs deployed in doctors’ offices may help to partly overcome offices may help to partly overcome physician-related factors that physician-related factors that undermineundermine patient activationpatient activation

Buffering Adverse Physician EffectsBuffering Adverse Physician Effects

Biases about certain groups, people, Biases about certain groups, people, and/or diagnosesand/or diagnoses

Social distanceSocial distance Fatalistic attitudes toward behavior changeFatalistic attitudes toward behavior change Clinical deficits (e.g. weak behavior Clinical deficits (e.g. weak behavior

change interviewing skills)change interviewing skills)

* = Factors that can be directly addressed with tailored IMCPs

** = Factors for which adverse effects on behavior may be “buffered” with tailored IMCPs

M = Mutable factors that tailored IMCPs can enhance

Theoretical model of factors influencing patient activation and health behavior

Key Depression IMCP Tailoring Key Depression IMCP Tailoring Variables or “Hinges”Variables or “Hinges”

Variable Measure

Depression symptoms, symptom burden

PHQ-9, plus items to characterize nature of self-harm thoughts

Depression-related visit agenda Investigator developed

Perceived depression causes Modified from Karasz et al

Depression self-stigma Adapted from Kanter et al

Depression treatment preference Investigator developed

Self-efficacy for talking about depression with doctors

Modified from Maly et al

Implications for Health DisparitiesImplications for Health Disparities

Vulnerable populations are disproportionately Vulnerable populations are disproportionately affected by all of the barriers to patient activation affected by all of the barriers to patient activation that tailored IMCPs might help to addressthat tailored IMCPs might help to address

Thus, greater deployment of tailored IMCPs Thus, greater deployment of tailored IMCPs (with equal access) might mitigate disparities(with equal access) might mitigate disparities

Ongoing National Cancer Institute-funded Ongoing National Cancer Institute-funded colorectal cancer screening project colorectal cancer screening project (R01CA131386 Jerant)(R01CA131386 Jerant)

When Does Tailored IMCP When Does Tailored IMCP Activation in the Doctor’s Office Activation in the Doctor’s Office

“Make Sense”?“Make Sense”? Complex topics that require a doctor’s expertise, Complex topics that require a doctor’s expertise,

evaluation, discussion, and/or treatmentevaluation, discussion, and/or treatment

Behaviors that depend heavily on doctor Behaviors that depend heavily on doctor behaviorbehavior

Behaviors for which multiple options exist, each Behaviors for which multiple options exist, each with pros/conswith pros/cons

When Does Tailored IMCP When Does Tailored IMCP Activation in the Doctor’s Office Activation in the Doctor’s Office

“Make Sense”?“Make Sense”?

In settings / populations with poor access In settings / populations with poor access to computer technology at hometo computer technology at home

Vast potential for application to myriad Vast potential for application to myriad behaviors, patient groups, settingsbehaviors, patient groups, settings

Practical Issues to Consider with Practical Issues to Consider with Office-Based Tailored IMCPsOffice-Based Tailored IMCPs

Target population:Target population: Literacy (general and health-related)Literacy (general and health-related) Familiarity with computersFamiliarity with computers Sensory and motor impairmentsSensory and motor impairments

Time constraintsTime constraints Physical settingPhysical setting Interface issuesInterface issues

Current Limitations and Current Limitations and Future IssuesFuture Issues

Office-based tailored IMCPs generally focus on Office-based tailored IMCPs generally focus on one-time, discrete behaviors (e.g. initial one-time, discrete behaviors (e.g. initial depression care seeking, colorectal cancer depression care seeking, colorectal cancer screening)screening)

Use of IMCPs to help bolster longer term Use of IMCPs to help bolster longer term behavior changes (e.g. healthy eating) needs to behavior changes (e.g. healthy eating) needs to be exploredbe explored


Lack of a model for wide dissemination of Lack of a model for wide dissemination of successful programs into daily practicesuccessful programs into daily practice


Current programs are generally touch screen laptop or Current programs are generally touch screen laptop or notebook basednotebook based

Cell phones and other personal digital devices are Cell phones and other personal digital devices are helping to narrow the “digital divide” somewhat and need helping to narrow the “digital divide” somewhat and need to be explored for delivering tailored informationto be explored for delivering tailored information

May be particularly useful in supporting patient efforts to May be particularly useful in supporting patient efforts to make and sustain longer term behavior changes, make and sustain longer term behavior changes, between office visits (reminder or “booster” messages)between office visits (reminder or “booster” messages)

Questions?Questions?

Documents

Tailored Interactive Multimedia Computer Programs (IMCPs) in the Doctor’s Office: Activating Patients with Technology Anthony Jerant, MD Paul Duberstein,