This project will develop an electronic prototype for collecting information from patients about health behaviors, including physical activity, stress, anxiety, depression and tobacco use. The study will involved four safety-net clinics to address the infrequent and inconsistent assessment of behavioral risk factors in primary care.

1. A Safety Net Collaboratory to Improve the
Use of Patient-Reported Outcome Measures
of Health Behaviors and Psychological Status
Beth Glenn, PhD, Hector Rodriguez, PhD, Roshan Bastani, PhD.
Community Partner: Bridget Hogan Cole, MPH,
Building Clinic Capacity for Quality (BCCQ), a program of Community Partners®
CERP Meeting
9/20/2012

2. Background
• Health behaviors and psychological status (e.g., tobacco use, poor
diet, depression) are infrequently and inconsistently assessed in
primary care despite their negative effects on health outcomes
• Standardized collection of patient-reported data on these health
topics is an important first step
• Establishment of clinic protocols to also systematically address
behavioral factors in primary care are critically needed
▫ Methods that maximize use of EHR hold the greatest promise for
routinization, institutionalization and sustainability
• Inclusion of safety net clinics and the vulnerable patients they
serve in these efforts is vital to reduce widening health disparities

3. NIH-Funded Pilot Study (10/11-9/12)
• Implemented a brief questionnaire to assess patient reported
data for 10 domains in 4 Federally Qualified Health Clinics in
Southern California
• Paper-and-pencil administration of “Patient Health Update” in
English, Spanish, and Chinese

4. Patient-Reported Behavioral Health Domains
Domain Final Measure (Source)
1.Demographics 9 items: Sex, date of birth, race, ethnicity, English fluency, occupation, household
income, marital status, education, address, insurance status, veteran’s status.
Multiple sources including: Census Bureau, IOM, and National Health Interview
Survey (NHIS)
2. Overall Health Status 1 item: BRFSS Questionnaire
3. Eating Patterns 3 items: Modified from Starting the Conversation (STC).
(Adapted from Paxton, AE et al. Am J Prev Med, 2011; 40(1):67-71.)
4. Physical Activity 2 items: The Exercise Vital Sign (Sallis, R. Br J Sports Med 2011; 45(6):473–474)
5. Stress** 1 item: Distress Thermometer (Roth AJ, et al. Cancer 1998; 15(82):1904-1908.)
6. Anxiety and 4 items: Patient Health Questionnaire - Depression & Anxiety (PHQ-4)
Depression (Kroenke K, et al. Psychosomatics 2009; 50(6):613-621.)
7. Sleep 2 items: a. Adapted from BRFSS
b. Neuro-QOL (Item PQSLP04)
8. Smoking/ Tobacco 2 items: Tobacco Use Screener (Adapted from YRBSS Questionnaire)
Use**
9. Risky Drinking** 1 item: Alcohol Use Screener (Smith PC, et al. J Gen Intern Med 2009; 24(7):783-788)
10. Substance Use ** 1 item: NIDA Quick Screen (Smith PC, et al. Arch Intern Med 2010, 170(13): 1155-
1160.)

5. Physical Activity Level
Q2a. How many days did you get moderate to strenuous exercise?
Q2b. On those days, how many minutes, on average, do you exercise at
this level?
33, 12%
Positive: Less than 150 min/week
Negative: More than 150 min/week
75, 26% Missing
176, 62%

6. Alcohol Use: Risky Drinking
Q7. How many times in the past year have you had X or more drinks in a day?
(Where X is 5 for men, and 4 for women)
5, 2%
70, 25%
Positive: 1 or more times
Negative: Never
Missing
209, 73%

7. Anxiety
Q4a. Feeling nervous, anxious, or on edge
Q4b. Not being able to stop or control worrying
17, 6%
56, 20%
Positive: Total score of 4 or more
Negative: Total score of less than 4
Missing
211, 74%

8. 10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
0.00%
FRTSVG
Q1b
Fruit & Veg Svgs
85.56%
Q2
Activity
Physical EXERCISE
61.97%
Q9
HEALTH
Overall Health
58.10%
STRESS
Q3
Stress
54.58%
Q1c
Bev
Soda/SweetSODA
30.28%
Q7
Alcohol ALC 24.65%
Anxiety
ANX/WOR PHQ
Q4a&b
19.72%
Q5
SNORE/SLEEP
Snore/Sleep
13.38%
DepressionPHQ
DEP/INT
9.51%
Q4c&d
Percentage of Positive-Screens by Measure
Q6a SMOKE1
Smoking
8.80%
Fast Food
FSTFOOD
Q1a
4.58%
Use
Q8
Drug DRUGUSE
3.87%
Smokeless Tob.
SMOKE2
Q6b
1.06%

9. 70
Distribution of Sample for Number of
63/22%
Positive Screenings
60
57/20%
50 48/17%
42/15%
40
Frequencies
30 29/10%
22/8%
20
12/4%
10
5/2%
4/1%
1/<1% 1/<1%
0
0
0 Positive 1 Positive 2 Positive 3 Positive 4 Positive 5 Positive 6 Positive 7 Positive 8 Positive 9 Positive 10 Positive 11-13
Screenings Screenings Screenings Screenings Screenings Screenings Screenings Screenings Screenings Screenings Screenings Positive
Screenings

10. CERP Pilot Project Aims
• Project Aim 1: In collaboration with Building Community Capacity
for Quality (BCCQ) convene a learning community comprised of 3-4
safety-net clinic organizations to understand current practices with
regard to the assessment of patient-reported measures of
behavioral risk factors and protocols to address these risk factors in
primary care settings. (Relevant to CERP Aim 1)
• Project Aim 2: Through a collaborative stakeholder engagement
process, select a set of patient-reported measures that can be
commonly collected across clinics participating in the learning
community. (Relevant to CERP Aim 2)
• Project Aim 3: Use data collected to inform development of a
prototype of an electronic patient-reported outcome data collection
and feedback system. (Relevant to CERP Aim 4)

11. Methods
• Convene a Learning Collaborative to Facilitate Sharing of Best Practices:
▫ Half day event scheduled for November 2012
▫ Working with BCCQ to select invitees-plan to include high level administrators or
medical director and information technology staff
▫ Plan to involve 3-6 organizations to keep group small and interactive
▫ Goal of event: provide opportunity for sites to share “best practices” for electronic
capture of behavioral risk factor data and using EHR and registry systems
• Organizational Assessment: Collection of data from each clinic participating in the
learning community with regard to current collection of patient-reported data for the
behavioral domains (i.e., method of collection, frequency of collection, target
population for assessment) and protocols in place for addressing these issues
• Key Informant Interviews with Clinic Administrators and Staff: Conduct key
informant interviews (2-3 informants per clinic) to understand stakeholder experiences
of PRO data collection, challenges & facilitators, interoperability between EHR and
other data systems, use of PRO data for reports and feedback

12. Methods
• Develop PRO Data Collection and Feedback Prototype: Use data to develop a
prototype that can be used to electronically capture data and facilitate
providers in addressing “out of range” patient values
▫ Prototype to produce easy-to-use views of patient data to allow for tracking
assessment over time and generating flags for “positive” results
▫ Goal to develop system that will be interoperable with many EHR systems
▫ Collaborating with technical team led by NIH’s Office of Behavioral and
Social Sciences Research

13. CERP aims addressed
• CERP Aim 1. Promote and sustain bidirectional knowledge
sharing between community and academia.
• CERP Aim 2. Strengthen community infrastructure for
sustainable partnered research.
• CERP Aim 4. Build health services research (HSR) methods into
partnerships to accelerate design, production, and wide
adoption of evidence-based practice and behavior.

14. Timeline
Finalize the collaboratory
participants
Organizational assessments of
community clinic structural capabilities
(current use of electronic data and
feedback systems)
Develop a prototype for
electronic PRO data
collection and feedback
Complete key (for later testing)
Key informant interviews informant interview Convene learning
of community clinic findings report collaborative Formal
stakeholders Testing
(November, 2012)
(clinicians and staff)
Develop a clinician
Finalize the set of resource guide for use in
PRO measures for next phase
inclusion in prototype
August-October, 2012 November 2012-February 2013

15. Added-Value from CTSI Funding
• Recently completed pilot allowed us to collect data from 4
Federally Qualified Health Center using paper-based methods
• CTSI funding allows us to take project to the next step:
▫ Focus on electronic capture of data
▫ Continued partnership with BCCQ will ensure involvement
of clinics with more HIT experience to share
▫ Comprehensive assessment of current practice and
solicitation of “best practices” in safety net will provide
valuable foundation for future work
▫ Development of a prototype will greatly facilitate ability to
address behavioral risk factors

16. Next Steps
• Dissemination of “lessons learned” to safety net
clinics
• Use pilot to apply for external funding to evaluate
the effect of prototype system more formally