The last few months have rapidly accelerated telehealth strategies as health systems pivot to deliver care in new ways. Primary care is a vital care setting in addressing mental health. People will often talk to their doctor about symptoms and emotions related to depression and anxiety. Leveraging digital mental health tools in this care setting and understanding deployment is a growing consideration as more care is delivered virtually.
A new paper by Andrea Graham and colleagues at Northwestern University, published in Translational Behavioral Medicine, shares lessons in deploying digital mental health tools in primary care.
Having digital mental health tools that reliably reduce symptoms is one aspect of deployment, but also important is the context in which these tools are deployed. This paper focuses on service design methods and how they can be leveraged to understand standard workflows for primary care teams. It also highlights which tools are best suited to refer patients to an app within an Electronic Medical Record (EMR).
The IntelliCare suite of digital mental health apps addresses anxiety and depression. Participant recruitment focused on people who scored in the moderate range for depression (PHQ9 score > 10) and via Facebook, social media marketing, flyers in doctors’ offices, and clinic-based outreach.
- Four hundred and thirty-five participants started the screening process, and 313 completed the entire process, of those one hundred and forty-six were randomly assigned. The average age of participants was 41 years old, and the average depression score was 14, indicating moderate depression.
- Direct to consumer recruitment strategies yielded the highest number of participants for the study. Clinical outreach was not as effective.
- A best practice alert was built into the workflow in the EMR to alert doctors that participants may be suitable. Upon reflection, doctors said this alert was not optimally timed in their workflow in practice as depression screening often happened before the doctor entering the exam room. The reality in clinical care is the patient may be coming in for a visit unrelated to their depressive symptoms, so it often competes for attention in the appointment and requires additional framing in the conversation.
- Doctors who had access to behavioral health at their local clinic were less likely to refer to the apps as they said their colleagues were better positioned to address them.
- Building orders into the EMR to refer to the tools was also delayed, as making changes to a core EMR takes a lot of time. This impacted the author’s ability to understand referral pathways fully. These are operational realities in health systems.
Overall this study shows how complex the implementation of digital mental health tools can be at the point of care. Doctor visits are not linear, and many things need to occur in any given visit. Having a best practice alert fire at the wrong time in a visit flow, even if designed in theory, clearly shows challenges in actual practice. Culture also matters. As more health systems seek to integrate behavioral health into primary care, doctors may default to their colleagues to address mental health issues that arise in that care setting.
This study is an essential addition to our understanding of how and where digital mental health tools can fit into existing care models. Leveraging service design methods allow systems to be built that better compliment workflow and points to cautions about being too linear in implementation. A one size fits all approach is not optimal.
Thanks for reading – Trina
(Opinions are my own)
Andrea K Graham, Carolyn J Greene, Thomas Powell, Pauli Lieponis, Amanda Lunsford, Chris D Peralta, L Casey Orr, Susan M Kaiser, MPH, Nameyeh Alam, Helom Berhane, Ozan Kalan, David C Mohr, Lessons learned from service design of a trial of a digital mental health service: Informing implementation in primary care clinics, Translational Behavioral Medicine, Volume 10, Issue 3, June 2020, Pages 598–605, https://doi.org/10.1093/tbm/ibz140