SummaryA group of medical practices incorporated a system into its daily workflow that prompt clinicians to offer behavior counseling and then refer patients to community services that could help them improve preventable health risks. The system, called Electronic Linkage System (eLinkS), prompts clinicians at the point of care to offer counseling to appropriate patients regarding diet, exercise, smoking, and alcohol consumption; once clinicians and patients agree on an appropriate counseling option, the system electronically sends referrals to community-based counseling organizations, which then proactively contact patients to arrange services. The program led to well-above average rates of referrals for counseling services, improved behaviors related to diet and exercise (which, in turn, led to weight loss), and enhanced quit rates among smokers.Moderate: The evidence consists of post-implementation data on referral rates and pre- and post-implementation comparisons conducted in nine primary care practices of key behavior-related metrics (e.g., smoking, weight loss, physical activity, alcohol abuse/misuse), as reported by patients in followup surveys.
Developing OrganizationsVirginia Commonwealth University Department of Family Medicine
Date First Implemented2006
Problem AddressedUnhealthy behaviors such as poor eating habits, sedentary lifestyles, smoking, and alcohol consumption contribute to high mortality in the United States. Clinicians typically provide little (if any) behavioral counseling services to patients, and those patients receiving referrals for external counseling services often do not pursue them on their own.
- Unhealthy behaviors lead to high mortality: Smoking, physical inactivity, poor diet, and problem drinking account for approximately 37 percent of deaths in the U.S. population.1
- Clinician advice influential, but often lacking: Behavior modification can be difficult, but individuals who succeed in modifying unhealthy behaviors cite physician recommendations as an important motivator.2 However, physicians often fail to provide such counseling, often because they forget or do not have time to do so. For example, one study found that only 40 percent of physicians assessed the physical activity status of patients.3 Another study of 12,835 obese adults found that only 42 percent were advised by their physician to lose weight.4 Furthermore, only 2 to 5 percent of patients are referred to community resources that offer behavioral counseling assistance.5
- Failure to pursue counseling: Even if physicians recommend behavioral change and external counseling services, patients often do not follow up on these recommendations on their own.6
Description of the Innovative ActivityA group of medical practices incorporated a system into its daily workflow that prompt clinicians to offer behavior counseling and then refer patients to community services that could help them reduce health-related risks. The system, known as eLinkS, prompts clinicians at the point of care to offer counseling to appropriate patients regarding diet, exercise, smoking, and alcohol consumption. Once clinicians and patients agree on an appropriate counseling option, the system electronically sends referrals to community-based counseling organizations, which then proactively contact patients to arrange services. Key elements of the program are described below:
Based on "5 A's" model: The program is based on the "5 A's" (ask, advise, agree, assist, arrange), a decades-old clinical model embraced by many organizations as an effective way to encourage changes in health-related behaviors.
Introduction of counseling services: At check-in or in the examination room, clinicians and staff members distribute a one-page flyer describing the different counseling services, including three intensive options (group counseling, telephone counseling, and computer care; see bullet on automated referrals below for more details on these programs). Use of the handout is optional; some clinicians instead prefer to describe the options verbally.
Data gathering: Once the patient is in the examination room, a staff member takes the patient's vital signs, measures height and weight, and inquires about smoking status ("ask"); the staff member enters this information into the electronic medical record (EMR). Staff do not query patients about alcohol use/misuse; this information is gathered by reviewing information from previous visits in the EMR, which documents the patient's response if the physician asked about alcohol use.
EMR prompt to clinician: If information in the patient's record reveals the presence of unhealthy behaviors, the EMR automatically prompts the clinician to consider providing counseling and referral services. The prompt, generated by a specially developed application known as eLinkS, lists the unhealthy behaviors and asks the clinician if the Prescription for Health form should be loaded.
Prescription for Health form: If the clinician answers "yes" to the prompt, eLinkS uploads a form that the clinician can use to document care and initiate a patient referral to appropriate counseling services. The form has boxes that can be checked by clinicians to document the following: whether they advised the patient to change his or her behavior ("advise"); whether the patient was willing to change behavior and seemed engaged in the process ("agree"); whether the patient wanted to be referred outside of the practice to one of the intensive counseling options ("assist"); and by what means (telephone contact, office visit, e-mail contact, or none) the patient wanted to follow up with the practice ("arrange"). Those who do not agree to outside counseling are considered to be receiving "usual care," which consists of any other alternative chosen by the patient and clinician (e.g., counseling by the clinician, pharmacotherapy, or no intervention). Clinicians may choose to click a button on the form labeled "View Patient Counseling Script" to review scripts that can be used to assist in providing advice to patients. Clinicians can also click a button labeled "Add Translation to Note" to transfer the information from the form to the encounter note, thereby automatically documenting the counseling in the medical record.
Automated referral to community-based counseling programs: When the clinician closes the form, eLinkS automatically e-mails a patient referral form to a designated counseling center with whom a referral relationship has previously been arranged. The counselor at the center logs onto a secure Web site (using a user name and password) to view the patient's contact information. The community-based options used by the practice (along with data on patient preferences for them) are described below, although counseling options can be tailored to available services within the community:
- Group counseling: Group counseling is offered by a commercial program for overweight and obesity (Weight Watchers), by the Riverside Hospital System wellness center for smoking, and by local chapters of Alcoholics Anonymous for risky drinking behavior. (Referrals to Alcoholics Anonymous are not automated; the clinician prints a list of available meetings to hand to the patient.)
- Telephone counseling: Trained counselors from the University of Kentucky Health & Wellness Behavior Health Improvement Program (BeHIP) provide telephone counseling for smoking cessation and weight loss.
- Computer care: Computer care provides patients with access to the My Healthy Living Web site (developed through the Prescription for Health program; see the Context section for more information), which includes about 200 local and national resources for patient self-management; computer care also includes an electronic counseling service, developed by University of Kentucky counselors, which follows BeHIP's telephone counseling protocol but allows online communication via a secure Web portal.
- Patient preferences: Participants indicate varying preferences for counseling services based on the behavior addressed; in general, group care and telephone counseling were preferred (computer care was rarely selected). For weight loss, roughly 70 percent of patients preferred group care, while approximately 30 percent preferred telephone counseling. For smoking cessation, approximately 70 percent of patients preferred telephone counseling, while approximately 30 percent preferred group classes.
Proactive contact to encourage participation: With the exception of referrals to Alcoholics Anonymous, representatives of the community-based programs proactively contact the referred patient to encourage participation and arrange for counseling services.
Counselor updates to patient record: At any time, the counselor can log onto the Web site to enter followup information; the Web site automatically sends information regarding the patient's progress back to the EMR so that it can be accessed by the patient's clinician.
Cost of counseling services: Grant funding allowed the program to provide up to 9 months of intensive counseling services free of charge to those patients who enrolled during a 5-week period (April 16, 2006 to May 22, 2006), after which the demand for referrals exceeded the project budget. After that time, eLinkS was modified so that patients referred to a counseling program were asked to pay for such services out of their own pocket or through their own insurance coverage. After 3 weeks, referrals dropped significantly (see Results section for more details), prompting program developers to secure funding from the Virginia Department of Health to cover telephone-based smoking cessation counseling. The eLinkS system was then reconfigured to provide referrals only for this type of counseling.
Context of the InnovationVirginia Commonwealth University sponsors the Virginia Ambulatory Care Outcomes Research Network (ACORN), a practice-based research network including more than 50 practices. This intervention was developed by ACORN as part of a grant from Prescription for Health, a 5-year initiative funded by The Robert Wood Johnson Foundation (RWJF) in collaboration with the Agency for Healthcare Research and Quality (AHRQ). This program was one of several initiatives funded through this grant to assist clinicians in helping their patients change health-related behaviors. The program was implemented in the Riverside Medical Group, a primary care organization with nine practices (ranging in size from 1 to 30 physicians) that participates in ACORN and is part of the Riverside Health System, a nonprofit system serving eastern Virginia. Riverside Medical Group serves a demographically diverse group of patients, with five practices located in suburban communities, one in a rural area, and one in an urban area. All Riverside Medical Group practices use the same EMR and share a central server.
ResultsThe program led to well-above average rates of referrals for counseling services, improved behaviors related to diet and exercise (which, in turn, led to weight loss), and enhanced quit rates among smokers.
Moderate: The evidence consists of post-implementation data on referral rates and pre- and post-implementation comparisons conducted in nine primary care practices of key behavior-related metrics (e.g., smoking, weight loss, physical activity, alcohol abuse/misuse), as reported by patients in followup surveys.
- High rate of patient referrals (until patients asked to pay for counseling services): During the initial 5-week period, the practices saw 5,679 patients, 4,030 of whom had unhealthy behaviors. Clinicians decided to use the prompt system for 576 encounters, and referred 400 patients for external counseling services, a referral rate of roughly 10 percent. Although no pre-implementation data are available, this figure is higher than published estimates of referral rates for smoking cessation and weight loss counseling, which are typically in the 2 to 5 percent range (or lower). However, once funding to cover the cost of counseling services ran out, referral rates fell by 97 percent,7 suggesting that providing resources to pay for counseling is likely necessary to ensure that appropriate referrals occur.
- Improvements in diet: Compared with baseline, survey results 4 months after implementation found that more patients reported eating five daily servings of fruits or vegetables (11 vs. 9 percent), limiting sweets (33 vs. 29 percent), and limiting fatty foods (47 vs. 43 percent).
Improvements in physical activity: Compared to baseline, survey results 4 months after implementation show that patients reported engaging in more vigorous activity (168 vs. 141 metabolic units of activity or METs), more moderate activity (305 vs. 253 METs), and more walking (366 vs. 332 METs).
Weight loss: Individuals referred for weight management counseling reported losing an average of 7 pounds 4 months after the referral, compared with no weight loss for patients receiving usual care.
Higher quit rates for smokers: Depending on the type of smoking cessation intervention, 50 to 75 percent of patients reported no longer smoking at 4 months after referral, compared with 25 percent of patients receiving usual care.
No impact on alcohol abuse/misuse: The system had no effect on the rate of alcohol use or misuse. The program developer believes that this could be due to several factors:
The documentation of alcohol misuse in the EMR might be limited, leading to incomplete identification of patients abusing alcohol.
Local counseling programs did not receive an automated prompt, and thus could not proactively contact the patient about participating.
Counseling services offered for alcohol use were not as extensive as for weight loss and smoking cessation.
Alcohol abuse may be a more difficult behavior to change. Many alcoholics do not want to stop drinking, while smokers and those who are obese are often more motivated to change behaviors.
Behavioral improvements sustained over time: Survey data 9 months after program implementation show gains that are similar to those achieved at 4 months.
Planning and Development ProcessKey steps in the planning and development process included the following:
Application design: Researchers at Virginia Commonwealth University designed the eLinkS application based on consultation with clinicians about what would be acceptable and helpful to them.
Identifying and partnering with community-based organizations: The research team identified potential community-based partners by asking Riverside Medical Group physicians about their current use of such services. The research team contacted these organizations to introduce the program, discuss service offerings, and set up a system for patient referrals.
Programming the EMR: Informatics staff programmed the eLinkS application into the EMR, without the assistance of an outside vendor. This relatively easy task involved pulling basic information from the EMR, designing the user interfaces (e.g., screens with prompts and forms), and automating a process to send that information to a secure Web site.
Training: Each of the nine practices hosted a 1-hour training session to ensure that clinicians knew how to use the system and understood the services offered by the counseling organizations. Counselors also attended these sessions to learn about the system and to receive user names that allow them to access the secure Web site.
Resources Used and Skills Needed
- Staffing: The program required no new staff, as existing practice-based informatics staff modified the EMR to include the eLinkS application. Research staff spent a small amount of time identifying community resources and training physicians and counselors.
- Costs: Program costs were minimal; as noted, the practice sites all used an existing EMR.
Funding SourcesAgency for Healthcare Research and Quality; Robert Wood Johnson Foundation
The program received initial funding under grant #053769 from RWJF and AHRQ as part of the Prescription for Health initiative; this grant covered the cost of counseling services for a 5-week period and an evaluation of the program's impact. Since these grant funds ran out, the program secured additional funding from the Virginia Department of Health to pay for telephone-based smoking cessation counseling.
Getting Started with This Innovation
- Identify health behaviors to be targeted: Adopters should review their patient populations to determine which health risks are most prevalent.
- Identify variety of local resources: A selection of services should be offered to accommodate patient preferences; some patients prefer self-management through computer-prompted care, whereas others might like the convenience of telephone counseling, and still others might prefer the more supportive environment offered by group visits.
- Emphasize benefits of linkages between physicians and community organizations: Because they typically work individually and are overburdened, physician practices and community counseling organizations may view it as burdensome to work closely together. Nevertheless, such a partnership can offer a "win-win-win" to participants: clinicians gain access to tools and resources to help their patients achieve behavior change; community counseling centers gain access to new patients; and patients improve their health while clinicians are kept informed of their progress.
- Obtain physician buy-in by emphasizing patient care benefits: Physicians are busy and often resist new care processes. Physicians should be assured that an automated counseling referral system will add only a few minutes to each visit but can have a meaningful, positive impact on patient health.
- Determine physician comfort level with EMR: The program will be easier to implement in practices that have an EMR in place that physicians feel comfortable using.
Sustaining This Innovation
- Pursue funding to cover counseling services: Patients may resist going to counseling services if they must pay for them out of their own pockets. As noted earlier, referral rates dropped by 97 percent after funds were no longer available to pay for counseling services; even minimal costs (e.g., $10 for a week of group counseling, $60 for a series of telephone sessions) can negatively affect use and uptake of this program. To reduce financial barriers, pursue grant funding and/or expanded insurer coverage of services, and identify free services that can be recommended to patients. For example, most states offer free smoking cessation telephone counseling (funded by tobacco lawsuit settlement funds) through a "Quit Line."
- Monitor and adapt to organizational and service changes: Over time, new clinicians and counseling organizations may enter the market, while others may exit it. In addition, service offerings in community counseling centers frequently change. As a result, would-be adopters need to develop a system to monitor and adapt to these changes.
- Match referral process to existing systems: Although eLinkS represents one example of an automated referral communication system, practices can develop other tools that fit their own resources and systems.
Spreading This InnovationThe developer is trying to secure grant funding to expand this program to practices throughout the state of Virginia.
Contact the InnovatorAlex H. Krist, MD, MPH
Associate Professor of Family Medicine
Virginia Commonwealth University
1200 East Broad street
PO Box 980251
Richmond, VA 23298-0251
Innovator DisclosuresDr. Krist has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this article.
References/Related ArticlesKrist AH, et al. An electronic linkage system for health behavior counseling: effect on behavioral outcomes. Unpublished manuscript provided by the developer.
Krist AH, Woolf SH, Frazier CO, et al. An electronic linkage system for health behavior counseling: effect on delivery of the "5 A's." Am J Prev Med. 2008;35(5 Suppl):S350-8. [PubMed]
Krist AH, Woolf SH, Johnson RE, et al. Patient costs as a barrier to intensive health behavior counseling. Am J Prev Med. 2010;38(3):344-8. [PubMed] Available at: http://www.ajpm-online.net/article/S0749-3797(09)00850-2/abstract
Mokdad AH, Marks JS, Stroup DF, et al. Actual causes of death in the United States, 2000. JAMA. 2004;291(10):1238-45. [PubMed]
2 Krist AH et al. An electronic linkage system for health behavior counseling: effect on behavioral outcomes. Manuscript provided by innovator.
Galuska DA. Are health care professionals advising obese patients to lose weight? JAMA. 1999;282(16):1576-8. [PubMed]
Krist AH, Woolf SH, Frazier CO, et al. An electronic linkage system for health behavior counseling: effect on delivery of the "5 A's." Am J Prev Med. 2008;35(5 Suppl):S350-8. [PubMed]
Interview with Dr. Alex Krist; June 12, 2008.
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Original publication: December 08, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: July 16, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: February 25, 2014.
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