SummaryA primary care clinic serving many low-literacy patients who may not have computer experience offers brief educational video modules via hand-held electronic devices. As appropriate, medical assistants, nurses, or physicians encourage patients to view these 3- to 5-minute modules during natural downtime in the visit. Existing modules cover colon cancer screening, anticoagulation management, asthma, diabetes, and general office information. The modules, which have been well accepted by both patients and staff, enhanced patient knowledge while placing little or no incremental demands on physicians and staff.Moderate: The evidence rating is based on post-implementation statistics on viewing of the anticoagulation modules, pre- and post-implementation comparisons of knowledge related to asthma management (with the post-implementation measure occurring right after viewing the module), and anecdotal feedback from patients and staff.
Developing OrganizationsWake Forest Baptist Health; Wake Forest University School of Medicine
Date First Implemented2009
The practice began offering video educational modules on desktop computers in 2000; it began testing similar modules on hand-held devices in 2008.
Patient PopulationThe program serves primary care patients, many of whom have low levels of literacy and limited experience using computers. Roughly one-third are covered by Medicare and another third by Medicaid; 10 percent have private insurance, and the remainder are self-pay patients.Vulnerable Populations > Illiterate/low-literate
Problem AddressedTime-pressed primary care physicians and their staff often do not have time to provide effective education to patients. This problem has gotten worse as office visits have shortened and educational tasks have grown.1 Computer-based education in general—and education via hand-held devices in particular—represent a potentially effective but currently underused way for primary care clinicians to deliver effective education without taking up additional time.
- Little time to educate: The typical time allotted for a primary care visit offers little opportunity for physicians or staff to educate patients. This problem continues to get worse as time pressures and educational demands increase.1 As a result, busy physicians either do not provide education or do so hurriedly, such as by handing the patient a brochure or asking other busy (and often less knowledgeable) staff to briefly educate the patient.
- Unrealized potential of computer-based education: For roughly a decade, multimedia computers have been used in some sites, although the approach tended to disrupt patient flow and often proved too costly to be considered useful.2,3 The greater flexibility and portability of hand-held devices enhance the ability of many sites to offer low-cost patient education without disrupting workflow or operations. Yet relatively few primary care practices offer education through portable devices.
Description of the Innovative ActivityA primary care clinic serving many low-literacy patients with limited computer experience offers brief educational video modules via hand-held electronic devices. As appropriate, medical assistants, nurses, or physicians encourage patients to view these 3- to 5-minute modules during natural downtime in the visit. Existing modules cover colon cancer screening, anticoagulation management, asthma, diabetes, and general office information. Key program elements are described below:
- Strategically placed devices with preloaded modules: The clinic currently has four hand-held devices (iPads®) strategically placed in the hallways. Each device has all available modules ready for viewing. (In an earlier iteration of the program, each of the clinic’s 10 nurses had a preloaded iPod® with headphones that could be distributed to patients.)
- As-needed viewing of modules: Depending on the module in question, medical assistants, nurses, or physicians will suggest a module viewing to the patient, give those expressing interest one of the devices, and help them access the module. To ensure privacy and avoid disrupting other patients, most patients view modules during natural downtime in the examination room (although some may be viewed near the nurses’ or checkout station). Available modules generally incorporate patient/family interviews, local imagery and scenery, and clinic staff to maximize their impact on the target audience. Modules cover the following areas:
- Colon cancer screening: At the end of the visit, physicians who order colon cancer screening for eligible patients suggest viewing a relevant module at checkout. Separate modules currently exist for flexible sigmoidoscopy and fecal occult blood test (FOBT). (A colonoscopy module has not yet been developed.) The modules explain the need for screening, the screening process (including necessary dietary and medication modifications) and, as appropriate, instructions related to procedure preparation or sample collection and mailing. Practice leaders are considering adding a brief module that lays out the various screening options to eligible patients.
- Anticoagulation modules: Patients taking an anticoagulant (or blood thinner) such as warfarin view one or more modules when they come in for their monthly International Normalized Ratio, or INR, measurement. (The INR provides a standard method for reporting the results of blood clotting tests.) The viewing occurs at the nurses’ station or checkout area during the approximately 5-minute waiting period after returning to the clinic from the laboratory. Currently, three separate modules exist that cover the following areas: the rationale for anticoagulation, INR monitoring and management, and nutrition advice.
- Asthma management: Patients with asthma can view any of three modules that cover various aspects of the condition, as outlined below:
- Self-assessment and warning signs: Nurses ask any patient who comes in for routine or urgent care if they have asthma. (The nurse inquires about asthma as one of several screening questions asked in the examination room.) They invite any patient with asthma to view a general module on self-assessment and warning signs that asthma may not be in control. Based on the Rules of Two® developed at Baylor Health Care System,4 the module covers asthma warning signs, such as taking a “quick-relief inhaler” more than two times a week and awakening at night with asthma more than two times a month.
- Environmental triggers: As appropriate, physicians suggest to patients with asthma that they view a video on environmental triggers that can lead to exacerbations. Patients typically view this module during the examination, with the physician sometimes leaving for a few minutes while the video plays and then returning to discuss the issue as needed with the patient.
- Asthma inhaler technique: As with the environmental triggers module, the physician may suggest viewing a video that covers appropriate inhaler technique, with subsequent discussion as needed.
- Diabetes management: As appropriate, physicians suggest that patients with diabetes view any of three modules: a general module on the importance of blood glucose monitoring through hemoglobin A1c measurement; a more detailed module on self-monitoring of glucose levels, including when to call the clinic; and a module on hypoglycemia.
- General office information: As appropriate, medical assistants encourage patients to view any of several modules that provide “news” related to the clinic, such as explaining recent changes (e.g., office hours, after-hour clinics) or conveying the importance of filling out patient satisfaction surveys. For example, one video informed patients about the clinic’s recent designation as a “patient-centered medical home.” Patients typically view these informational videos after the assistant takes vital signs in the examination room (during downtime before the doctor enters).
Context of the InnovationLocated in Winston-Salem, NC, the Downtown Health Plaza operates as a community health center, providing primary care services to 10,000 local residents and handling 60,000 patient visits a year. An outpatient department of North Carolina Baptist Hospital, this urban clinic is staffed by more than 50 physicians and mid-level practitioners employed by the Wake Forest University Baptist Medical Center. This program was implemented in the center’s adult medicine clinic, staffed by 10 attending physicians, 38 resident physicians, 5 nurses, and 5 certified nursing assistants who handle more than 20,000 clinic visits each year. As noted, many patients served by the adult medicine clinic are covered by Medicaid or are uninsured, and many have low literacy and no Internet access. Clinic leaders started this program as a way to improve patient education without placing additional demands on physicians and staff. The center had been experimenting with computer-assisted patient education for a number of years, and leaders felt that using hand-held devices offered greater portability and flexibility than traditional computers.
ResultsThe program enhanced patient knowledge while placing little or no incremental demands on patients, physicians, nurses, and other staff.
Moderate: The evidence rating is based on post-implementation statistics on viewing of the anticoagulation modules, pre- and post-implementation comparisons of knowledge related to asthma management (with the post-implementation measure occurring right after viewing the module), and anecdotal feedback from patients and staff.
- Broad patient participation: Most patients participate in the program, viewing one or more modules per visit. During a pilot test of the anticoagulation modules, 70 percent of the 130 patients who came to the clinic for an INR check completed at least one module, with 17 percent completing all 3 and only 7 percent refusing to participate.5
- Enhanced knowledge: The modules have enhanced patient knowledge in several areas, as outlined below:
- Asthma: Among 50 patients taking a knowledge test right before and after completing the asthma self-assessment module, the percentage that knew the correct number of rules in the “Rules of Two,” rose from 10 percent before the test to 70 percent afterward. Similarly, the percent able to name at least 1 of the 4 rules rose from 4 to 78 percent, and the percent knowing the meaning of a positive response increased from 34 to 86 percent. Overall, nearly 40 percent (19 of 50) of patients learned the answer to all 3 of these questions from the module, while 16 others learned answers to 2 of the 3 questions. (Only 4 percent knew all the answers before completing the module, and only 10 percent did not learn anything from the module.)6
- FOBT: A randomized trial of an earlier, desktop computer–based version of the FOBT module found that it enhanced patient knowledge and the intention to be screened, with results similar to those achieved through nurse counseling.7 Although the updated (nearly identical) FOBT module for the hand-held device has not been formally evaluated, program leaders believe it is having a similar impact.
- Positive feedback from patients and staff: The 22 patients completing all 3 anticoagulation modules rated the helpfulness of the education experience as 7.4 (on a 10-point Likert scale, with a “1” being not helpful and a “10” being very helpful), significantly above the 6.3 rating given to their previous education on anticoagulation. Nurses and other staff expressed support for the anticoagulation modules and interest in expanding the concept to other conditions.5
- Little incremental burden: Patients completing the anticoagulation modules reported that the education added no more than 1 to 5 minutes to their visit. For their part, physicians and staff reported little or no time delivering this routine education, thus freeing up time for other tasks during time-pressed visits.5
Planning and Development ProcessClinic staff have created the various modules over time, developing new modules based on need. In general, the development process works as follows:
- Choosing topics: Clinic personnel engage in brief discussions and conduct focus groups during regular staff meetings to identify high-priority topics that lend themselves to education via hand-held devices.
- Content development: Physician and/or nurse champions within the clinic recruit and work with relevant staff to create each module, with a target length of approximately 3 minutes. Using widely available software, digital media capture, and computer-based recording equipment, staff members create voiceovers, imagery, animation, and video to make the material come alive, with the goal of providing culturally appropriate education to a low-literacy audience. The clinical content generally comes from a review of past patient education efforts and relevant literature, along with focus groups with physicians and nurses. Modules incorporate interviews with actual patients/families, local imagery and scenery, and other techniques to enhance resonance with the target audience. The development process typically takes about a month.
- Pilot testing and refinement: Modules generally undergo a pilot test with 25 to 50 patients to ensure their effectiveness, with refinements made as needed.
- Transition from older technologies: In some cases, modules originally developed for the desktop computer have been transitioned to hand-held devices. Also, as noted, some modules were originally created for use with a small, portable device with headphones in public areas of the clinic. After the introduction of hand-held tablet computers, clinic leaders decided to transition the modules for use with this technology. Leaders also decided to stop using the headphones (as patients worried about spread of infection), and hence began looking for ways to allow patients to view as many modules as possible in the examination room or other, more private areas.
- Ongoing expansion: Clinic leaders hope to create Spanish versions of the modules and plan to continue identifying high-priority topics for future modules. The program will soon be expanded to the pediatrics and obstetrics/gynecology departments within the community health center and to a “sister” internal medicine clinic.
Resources Used and Skills Needed
- Staffing: The program requires no incremental staff, as existing staff develop the modules and assist patients with viewing them as part of their regular duties.
- Costs: Program-related costs are minimal, consisting primarily of the purchase of the hand-held devices and a video camera. For the most part, modules are created using software that comes with standard computer equipment already in the practice.
Funding SourcesWake Forest University School of Medicine; Wake Forest Baptist Health
The state Medicaid program provided some funding to assist with equipment purchases.
Getting Started with This Innovation
- Conduct needs assessment: Working with nurses and physicians, review current needs related to patient education, along with the adequacy of available resources to meet those needs. This analysis will help to identify high-priority areas for patient education. In some cases, high-priority areas may be defined by national organizations—for example, the clinic developed the anticoagulation modules in response to Joint Commission directives to enhance safety in this area.
- Involve staff from beginning: Clinic personnel should be involved at every stage of module development. Staff can provide valuable input to guide development and refinement, and including them also helps to win their support of the program.
- Avoid interactive features: These modules are intended to educate patients in a short period of time, leaving little or no time for applications that require the patient to interact with the device.
- Incorporate familiar people, images: Use of familiar staff, patients and family members (e.g., through interviews), and local imagery and scenery can maximize resonance, especially with low-literacy patients.
- Focus on smaller, portable technologies: Smaller, portable platforms are more likely to be used than larger ones (e.g., desktop computers), as they offer more flexibility to both patients and staff.
- Conduct small pilot tests, refine accordingly: As noted, pilot testing allows for quick evaluation of module effectiveness and for timely identification and resolution of issues.
Sustaining This Innovation
- Be discriminating in suggesting modules for viewing: Patients cannot view too many modules during a single visit without disrupting the flow. In addition, both patients and staff may lose enthusiasm for the program over time if too many modules are used. To avoid this problem, be strategic and discriminating about which modules to suggest, and consider using only one “featured” general information module each month.
- If feasible, monitor impact over time: To the extent possible, gauge the impact of the education on patients over time. Although this program showed immediate gains in knowledge, the impact on long-term retention and self-management behaviors remains unknown. If time and financial resources allow, consider conducting additional knowledge tests and/or other data collection and analysis to gauge the long-term impact.
Spreading This InnovationThe program is being adopted by another private pediatric practice in the Winston-Salem area.
Contact the InnovatorJames L. Wofford, MD, MS
Department of Internal Medicine
Wake Forest University School of Medicine
Winston-Salem, NC 27157
Innovator DisclosuresDr. Wofford has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
References/Related ArticlesWofford JL, Stevens S, Brown K. Teaching asthma self-assessment through computer-assisted patient education: a pilot study. Prim Care Respir J. 2011;20(2):218. [PubMed]
Denizard-Thompson NR, Singh S, Stevens SR, et al. iPod™ Technology for teaching patients about anticoagulation: a pilot study of mobile computer-assisted patient education. Prim Health Care Res Dev. 2012 Jan;13(1):42-7. [PubMed]
Denizard-Thompson N, Singh S, Wells MD, et al. Using iPod technology for warfarin education: mobile computer-assisted patient education for improving office efficiency. J Gen Intern Med 2008;23(2):230.
Miller DP, Kimberly JR, Case LD, et al. Using a computer to teach patients about fecal occult blood screening. J Gen Intern Med 2005;20:984-88. [PubMed]
Wofford JL, Currin D, Michielutte R, et al. The multimedia computer for low literacy health education: a pilot study of cancer risk. MedGenMed 2001;3(2):23. [PubMed]
Yarnall KS, Pollak KI, Ostbye T, et al. Primary care: is there enough time for prevention. Am J Publ Health. 2003;93,635–41. [PubMed]
Wofford JL, Wells MD, Singh S. Best strategies for patient education about anticoagulation with warfarin: a systematic review. BMC Health Serv Res. 2008;8:40. [PubMed]
Krishna S, Balas EA, Spencer DC, et al. Clinical trials of interactive computerized patient education: implications for family practice. J Fam Pract. 1997:45,25-33. [PubMed]
4 Hart MK, Millard MW. Approaches to chronic disease management for asthma and chronic obstructive pulmonary disease: strategies through the continuum of care. Proceedings (Baylor University Medical Center). 2010;23:223-9.
Denizard-Thompson NR, Singh S, Stevens SR, et al. iPod™ Technology for teaching patients about anticoagulation: a pilot study of mobile computer-assisted patient education. Prim Health Care Res Dev. 2012;13(1):42-7. [PubMed]
Wofford JL, Stevens S, Brown K. Teaching asthma self-assessment through computer-assisted patient education: a pilot study. Prim Care Respir J. 2011;20(2):218. [PubMed]
Miller DP, Kimberly JR, Case LD, et al. Using a computer to teach patients about fecal occult blood screening. J Gen Intern Med. 2005;20:984-88. [PubMed]
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Original publication: June 08, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: July 30, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: May 21, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.