# Presentation: 006376

## Conversational IT for Better, Safer, Pediatric Care William G. Adams, MDAssociate Professor of PediatricsDirector of Child Health InformaticsBoston Medical Center/Boston University School of Medicinebadams@bu.edu

## Slide 2

## A Critical Role for Patient-Centered HIT

- Limits of clinician-centered HIT
- Pressing need to:
- Respond to individuals
- Engage patients outside clinical settings
- Provide access to personal medical information
- Empower patients to be active participants in decisions and daily management
- Consider unique constraints for child-centered systems

## Conversational IT

- Speech-based
- Bidirectional
- Informative
- Adaptive
- Intelligent

## Why Telephony?

- Conversational
- Ubiquitous
- Directed
- Scalable
- Outbound

## Three Child-centered Conversational Systems

- TLC-Asthma
- Healthy Eating and Activity Today (HEAT)
- Personal Health Partner (PHP)

## TLC-Asthma: An Integrated Information System for Child-centered Monitoring and Case Management

## Four age-specific child scripts (Grades K-1, 2-3, 4-6, 7+)
6 rotating modules
Separate scripts for parents
Modules 
monitor and teach
alert nurse case manager

- 6 rotating modules
- Separate scripts for parents
- Modules
- monitor and teach
- alert nurse case manager

- TLC-Asthma Scripts

## TLC-Asthma Alert Summary*

|  | Child
# (%) | Parent
# (%) |
| --- | --- | --- |
| Child seriously ill | 23(4) | 3(1) |
| Persistent asthma symptoms | 167(31) | 100(22) |
| Missed school due to asthma | 21(4) | - |
| Medication change | 54(10) | 61(13) |
| Needs refill | 25(5) | 25(5) |
| Medication knowledge deficiency | 66(12) | 50(11) |
| Rx does not match symptoms | 34(6) | 54(12) |
| Excessive reliever med. use | 95(18) | 91(20) |
| Persistent trigger exposure | - | 9(2) |
| Peak flow monitoring problem | 33(6) | 55(12) |
| No action plan | 3(1) | 3(1) |
| Other | 13(2) | 6(1) |

- * 6 month intervention, 79 intervention families

## TLC-Asthma – Results

- No difference in ER visits, hospitalizations, or spirometry
- 36% decrease in daytime symptom-days
- 25% increase in symptom-free days
- 67% fewer missed school days
- Increased effect in heavier users

- Preliminary, unpublished findings

## The Healthy Eating and Activity Today (HEAT) Program:Telephony-based Self Care for Overweight Children

## HEAT

- Two evidence-based programs
- Traffic Light Diet (TLC, Epstein et al)
- Student Media Awareness to Reduce Television (SMART, Robinson et al)
- 9-12 yr old children in early stages of overweight ( BMI _<_ 5 above 95 %’ile)
- Child’s parent participates with child
- PCP supports family’s efforts

## Theoretical Foundation for HEAT Content

| Component | Theory/goal |
| --- | --- |
| Greeting and positive praise or encouragement for sticking with the program | Reinforcement to build adherence to the program |
| Follow-up on challenge / goal set in the previous call | Contingency management, rewards |
| Educational topic related to weight management strategies | Building behavioral capability |
| Assessment related to the topic of the call | Self-monitoring / self-awareness |
| Challenge / goal setting related either to the previous challenge or to the topic of the day | Building self-efficacy / goal setting
Implementation intention |
| Summary statement / closing to wrap up what was discussed |  |

## Slide 14

## The Personal Health Partner (PHP)

- Pre-visit conversation with parent
- Pediatric primary care and medication safety
- RCT (assigned at time of call):
- Usual Care
- Assessment (w/ EHR Integration)
- Assessment, Counseling, and Activation

## PHPSystemArchitecture

- PHPSystemArchitecture

- Anywhere

- Communication Gateway Server (Envox)

- vXML Application Server (Tomcat)

- Database
- (SQL Server)

- Speech Recognition (ASR) and Text-to-Speech (TTS) (Loquendo)

- Network

- Clinician

- Primary Care Center

- Parent

- EHR (Logician)

- vXML Script Development Software (Envox)

## Hypotheses

- PHP use will be associated with more comprehensive visits
- PHP counseling will improve parental:
- Knowledge
- Behavior
- Activation
- PHP will improve efficiency by pre-populating RHCM form in EHR

## PHP

- Study Design

## PHP Assessment Samples

| Topic | Trigger | Activation |
| --- | --- | --- |
| Parental Smoking | Caller is smoker | Call local/national quit line |
| Child Development | Failed Screening | Discuss concerns with PCP, offer EI phone number |
| Maternal Depression | Positive screen (PHQ2), no current treatment | Call/find parent PCP, discuss feelings with pediatrician |
| TB Risk | At risk, due for screening | Remind clinician to do PPD |
| Medication Reconciliation | Inactive or undocumented med in EHR Med List | NA (physician notified via EHR) |
| Medication Use | On prescription meds | Bring medication to visit |
|  | Dosing errors | Discuss dosing with clinician |
|  | Asthma reliever used as controller | Bring medication to visit and discuss use with clinician |

## Demonstration

## PHP: Year 1 Activities

- Script development (questions, triggers, counseling, activation)
- New script data model and tools
- EHR data and user interfaces
- Focus group planning

## Slide 22