StartSmart(TM): Health Information Technology to Improve Adherence to Prenatal Guidelines (Colorado)

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StartSmart(TM): Health Information Technology to Improve Adherence to Prenatal Guidelines - Final Report

Citation:
Gance-Cleveland B. StartSmart(TM): Health Information Technology to Improve Adherence to Prenatal Guidelines - Final Report. (Prepared by the University of Colorado under Grant No. R21 HS024738). Rockville, MD: Agency for Healthcare Research and Quality, 2019. (PDF, 1.14 MB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
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Smart Mobile Health App Improves Screening for Risks and Protective Factors for Pregnant Women

COMPLETED RESEARCH – KEY FINDINGS AND IMPACT

A screening tool for risk and protective factors during pregnancy can be integrated in clinic flow and improve customized discussions with pregnant women to improve outcomes for pregnant women and their babies.

Screening for risks and protective factors to improve perinatal outcomes is not consistently done

Many conditions and lifestyle factors during pregnancy impact a woman’s health, as well as the health of her child. Despite advancements in perinatal healthcare in the United States, there has been little improvement in infant morbidity and mortality, and rates of maternal morbidity continue to rise. Research links poor perinatal outcomes to risks such as mental health conditions, substance misuse, and chronic diseases during pregnancy. In addition, protective factors including immunizations, nutrition, physical activity, and sleep can influence pregnancy outcomes; however, pregnant women are not consistently counseled on these factors. While the American College of Obstetricians and Gynecologists and the American College of Nurse Midwives have issued guidelines that can influence outcomes, adherence to these guidelines is limited due to lack of awareness, time constraints, and competing clinic demands.

Gathering iterative feedback from providers and patients to develop the StartSmart™ app

To address these issues, Dr. Bonnie Gance-Cleveland and a team of researchers at the University of Colorado developed, evaluated, and implemented a comprehensive screening tool using a mobile health app to generate individualized, evidence-based recommendations around pregnancy risk and protective factors to improve outcomes. StartSmartTM includes screening, decision support, and brief interventions for weight status and related conditions such as gestational diabetes; substance misuse and tobacco use; emotional conditions such as anxiety, depression, and domestic violence; and protective factors including immunizations, prenatal vitamins, physical activity, and sleep. Additional features include tailored patient recommendations and provider prompts for brief motivational interviewing counseling. When used, pregnant women complete the screen on a tablet during a perinatal visit; the support staff enter the patient’s height, weight, blood pressure, immunization and lab information; and the app generates a provider summary of the screening. In addition, the app also provides the ability to print educational materials for the patient.

During development, feedback from providers and patients was elicited to guide content. One important item identified by providers was the need for an intimate partner violence screen. Inclusion of this screen in the app was affirmed by one non-U.S. born woman during patient interviews: "I'm glad you're asking this question with the tablet because in my country we're not allowed to talk about it, but I can tell you using the tablet. Many women need help with this."

“Some of the providers said they thought their colleagues had preconceived notions about who was using substances and who wasn't or who had mental health issues. They were not universally screening patients and were actually screening patients based on who they thought had a problem. I don't believe you can tell by looking who has depression or who uses substances, and we should be universally screening everyone. And I think if we just say these are questions we ask everybody, people feel less ostracized by the questions.”
– Dr. Gance-Cleveland

Tool supports screening for perinatal risk and protective factors

While providers and staff reported some workflow issues with using the tool and concerns around disruption to workflow, they found the tool to be helpful in customizing discussions with patients around risk and protective factors. As one provider noted, “It helped me to efficiently ask about things I otherwise wouldn't have time for.” Based on the success of the initial iteration of StartSmartTM. Dr. Gance-Cleveland and her team received additional funding to create a Spanish-language version and are seeking funding to integrate the tool within a health system’s EHR.

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A screening tool for risk and protective factors during pregnancy can be integrated in clinic flow and improve customized discussions with pregnant women to improve outcomes for pregnant women and their babies.

Project Details - Ended

Summary:

Many conditions and lifestyle factors during pregnancy impact a woman’s health as well as the health of her child--some effects lasting long after birth. Despite advancements in perinatal healthcare, infant morbidity and mortality have seen little improvement in this country, and rates of severe maternal morbidity have continued to rise. Evidence points to a link between poor perinatal outcomes and pregnancy health risks, and yet adherence to prenatal guidelines that address these risks is not optimal. In addition, pregnant women are not consistently counseled on protective factors that can influence pregnancy outcomes, such as immunizations, nutrition, physical activity, and sleep. The use of technology to generate individualized, evidence-based recommendations around pregnancy risk and protective factors may lead to improved outcomes.

This research developed and evaluated a mobile health application (app) called StartSmart, to improve screening, intervention, and referrals in the care of pregnant women.

The specific aims of the project were as follows:

  • Develop StartSmart™ to screen pregnant women for health risk and protective factors throughout pregnancy and to generate individualized, evidence-based recommendations for these factors. 
  • Alpha test StartSmart™ and refine technology based upon patient and provider feedback. 
  • Beta test and refine StartSmart™ based on patient and provider feedback on acceptability and usability. 

The researchers began by developing a prototype of StartSmart™ through an iterative process that incorporated patient and provider feedback in each phase. Development of the app was informed by consultation with expert clinicians, scientists, and patients, with a goal of optimizing screening of pregnant women for prenatal risk and protective factors. Features of the tool include the generation of clinical decision support, tailored patient recommendations, and provider prompts for brief motivational interviewing counseling. After the prototype was developed, patients and providers were interviewed to provide feedback. Researchers observed the use of the tool in the clinic setting and conducted process mapping to understand the impact on patient flow as well as workload for medical assistants and front desk staff. Future interoperability with electronic health records was tested by establishing StartSmart™ connectivity with a publicly available and Fast Healthcare Interoperability Resources-compliant server. The researchers hope that the tool can aid providers in addressing pregnancy risk and protective factors in an individual and targeted manner, which may improve maternal and child health.