The Virtual Patient for Improving Quality of Care in Primary Healthcare (Massachusetts)

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Summary:

Traumatic experiences are associated with negative health behaviors, such as poor diet, smoking, sedentary lifestyle, and alcohol and substance abuse, and are also associated with post-traumatic stress disorder (PTSD) and depression. Refugees are an example of a highly-traumatized patient population who demonstrate high rates of PTSD, depression, and physical disabilities. Traumatized refugees seeking health care face many barriers related to socioeconomic status, cultural and medical worldviews, limited English proficiency, and low levels of health literacy. In order to care for this population, primary care providers (PCPs) must be: 1) aware of the trauma-related mental and physical health problems that refugee populations often experience, 2) knowledgeable of the barriers to health care that refugee populations may face and how to overcome them, and 3) able to identify and treat trauma as a medical and mental health risk factor in a culturally sensitive way.

This project developed and implemented a virtual patient, previously established as an efficient and cost-effective training tool, to help train PCPs in diagnosing and treating trauma-related medical and mental health conditions for refugee populations.

The specific aims of this project were as follows:

  • Develop a virtual patient β-prototype from an existing α-prototype to be an effective and engaging learning tool for PCPs. 
  • Test the ability of the virtual patient β-prototype to improve the primary care physicians’ identification and screening of health and mental health problems in traumatized and culturally diverse patients. 
  • Test the ability of the virtual patient β-prototype to improve the primary care physicians’ treatment management plan of the health and mental health problems of traumatized diverse patients. 
  • Assess the feasibility of expanding the use of the virtual patient among primary care physicians at neighborhood health centers. 

This feasibility project was conducted in two stages. First feedback and recommendations, collected from 10 PCPs undergoing the α-prototype training, were incorporated into the development of the β-prototype. The second phase consisted of a case-based assessment of 24 PCP’s knowledge of trauma before and after completing the β-prototype training. The case assessment showed assessments improved in some areas, but not in others.

This project was the first to educate and train PCPs on the diagnosis and treatment of a traumatized refugee patient in primary health care using a virtual patient. While readily accepted by PCPs, there is additional need for analysis to understand why trauma assessments did not improve in all areas with the use of the virtual patient.

The Virtual Patient for Improving Quality of Care in Primary Healthcare - 2012

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS 08-269: Exploratory and Developmental Grant to Improve Health Care Quality through Health Information Technology (IT) (R21)
  • Grant Number: 
    R21 HS 020323
  • Project Period: 
    September 2011 – September 2013
  • AHRQ Funding Amount: 
    $296,320
  • PDF Version: 
    (PDF, 306.76 KB)

Summary: Traumatic experiences can have significant impact on mental and physical health. It is well established that trauma is associated with post-traumatic stress disorder (PTSD) and depression. Traumatic experiences are also associated with negative health behaviors, such as poor diet, smoking, sedentary lifestyle, and alcohol and substance abuse. Refugees are an example of a highly traumatized patient population that demonstrates high rates of PTSD, depression, and physical disability. Traumatized refugees seeking health care often face many barriers related to socioeconomic status, cultural and medical worldviews, limited English proficiency, and low levels of health literacy. Primary care providers (PCPs) must be: 1) aware of the trauma-related mental and physical health problems that refugee populations often experience; 2) knowledgeable of the barriers to health care that refugee populations may face and how to overcome them; and 3) able to identify and treat trauma as a medical and mental health risk-factor in a culturally sensitive way.

Dr. Richard Mollica and his research team at the Harvard Program in Refugee Trauma at Massachusetts General Hospital are collaborating with researchers at the Karolinksa Institute’s Virtual Patient Lab in Stockholm, Sweden, to develop a virtual patient (VP) that will help train PCPs to diagnose and treat trauma-related medical and mental health problems among highly traumatized refugee populations. A VP is an interactive computer simulation that provides a representation of a patient encounter for learning and assessment. The VP has been established as an efficient and cost-effective training tool in health care. This project will implement a VP in primary care settings to help providers build clinical capacity for the cultural and evidence-based identification and treatment of traumatized refugee patients from disadvantaged, diverse backgrounds.

This project is being conducted in two phases. Phase I involved developing the VP β-prototype from the existing VP α-prototype. PCPs from the Lynn Community Health Center (LCHC) in Boston, Massachusetts, were recruited to participate in the development process. These PCPs participated in a three-part series in which the VP was first described and the VP α-prototype was presented to the PCPs. Semi-structured interviews and surveys were administered pre- and post-test to collect information on the PCPs’ preconceptions, attitudes, thoughts on usefulness, and recommendations for informing the development of the VP β-prototype.

Phase II of the project involves testing the effectiveness of the VP β-prototype to improve the ability of PCPs at LCHC to identify, screen, and treat the physical and mental health problems of the traumatized refugee patients. The VP β-prototype will be administered to 30 PCPs, including those who participated in Phase I of the project and at least 20 additional, randomly selected PCPs at LCHC. The PCPs will participate in three onsite sessions at which they will be administered clinical cases for patient assessment and the development of a treatment plan, followed by an introduction and review of the VP β-prototype.

A survey will be used to rate the quality of the PCPs’ treatment plans pre- and post-viewing of the VP β-prototype. Additionally, the semi-structured interviews and surveys used in Phase I of the study will be administered to the Phase II PCPs pre- and post-viewing of the VP to assess the PCPs’ perception of the VP β-prototype as a training and clinical tool. A followup phone call will collect data from the PCPs on the strengths and weaknesses of the VP and their recommendations for improving the prototype.

Specific Aims:

  • Develop a final Virtual Patient β-prototype (from the existing α-prototype) that is perceived as an effective and engaging learning tool by primary care physicians. (Achieved)
  • Test the ability of the Virtual Patient β-prototype to improve the primary care physicians’ identification and screening of health and mental health problems in traumatized and culturally- diverse patients. (Ongoing)
  • Test the ability of the Virtual Patient β-prototype to improve the primary care physicians’ treatment management plan of the health and mental health problems of traumatized diverse patients. (Ongoing)
  • Assess the feasibility of expanding the use of the Virtual Patient among primary care physicians at neighborhood health centers. (Ongoing)

2012 Activities: Questionnaires used for measuring PCPs’ perceptions of and experiences with the VP were developed. Eleven PCPs from LCHC participated in the Phase I pre- and post-testing of the VP and the existing VP α-prototype. Findings from Phase 1 were analyzed and applied to develop the β-prototype of the VP. A scoring system was developed to be used during the testing of the VP β-prototype, along with two paper clinical cases that will be used in Phase II testing of the VP. Activities for 2013 include recruiting an additional 20 to 25 PCPs to review and score the paper clinical cases and use the VP to assess them to determine which approach results in a more effective treatment management plan.

As last self-reported in the AHRQ Research Reporting System, project progress and activities are completely on track, and project budget funds are somewhat overspent.

Preliminary Impact and Findings: This project has no findings to date.

Target Population: Mental Health/Depression, Racial or Ethnic Minorities*: Bosnian Refugees

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Synthesis and Dissemination

* This target population is one of AHRQ’s priority populations.

The Virtual Patient for Improving Quality of Care in Primary Healthcare - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-269: Exploratory and Developmental Grant to Improve Health Care Quality through Health Information Technology (IT) (R21)
  • Grant Number: 
    R21 HS 020323
  • Project Period: 
    September 2011 - September 2013
  • AHRQ Funding Amount: 
    $296,320
  • PDF Version: 
    (PDF, 201.25 KB)

Summary: Traumatic experiences can have significant impact on one's mental and physical health. It is well established that trauma is associated with posttraumatic stress disorder (PTSD) and depression. Traumatic experiences are also associated with negative health behaviors - such as poor diet, smoking, sedentary lifestyle, and alcohol and substance abuse - that compromise physical health. Refugees are an example of a highly-traumatized patient population demonstrating high rates of PTSD, depression, and physical disability. Traumatized refugee patients seeking health care may face many barriers related to socioeconomic status, cultural medical worldviews, limited English proficiency, and low levels of health literacy. In order to effectively diagnose and treat highly traumatized refugees, primary care providers (PCPs) need to be trained in accurate diagnosis and treatment. Specifically, PCPs need to be 1) aware of the trauma-related mental and physical health problems that refugee populations often experience; 2) knowledgeable of the barriers to health care refugee populations may face and how to overcome them; and 3) able to identify and treat trauma as a medical and mental health risk factor in a culturally-sensitive way.

Dr. Richard Mollica and his research team at the Harvard Program in Refugee Trauma at Massachusetts General Hospital are collaborating with researchers at the Karolinksa Institutet's Virtual Patient Lab, in Stockholm, Sweden, to develop a virtual patient (VP) that will help train PCPs to accurately diagnose and treat trauma-related medical and mental health problems among highly-traumatized refugee populations. A VP is an interactive computer simulation that provides a virtual representation of a patient encounter for learning and assessment. The VP has been well established as an efficient and cost-effective training tool in health care. This project will implement a VP in primary care to help providers build their clinical capacity for the cultural and evidence-based identification and treatment of traumatized refugee patients from disadvantaged, diverse backgrounds.

This project is being conducted in two phases. Phase I involves the development of the VP (BETA)-prototype from the existing VP (ALPHA)-prototype. Ten PCPs from the Lynn Community Health Center (LCHC) in Boston, Massachusetts, were recruited to participate in the development process. These PCPs will participate in a three-part series in which the VP is first described and the VP (ALPHA)-prototype is then presented to the PCPs. Semi-structured interviews and surveys will be administered as a pre-test and post-test to collect information on the PCPs’ preconceptions, attitudes, thoughts on usefulness, and recommendations for informing the development of the VP (BETA)-prototype.

Phase II of the project will test the effectiveness of the VP (BETA)-prototype to improve the abilities of PCPs at LCHC to identify, screen, and treat the physical and mental health problems of the traumatized refugee patient presented by the VP (BETA)-prototype. The VP (BETA)-prototype will be administered to 30 PCPs, including the 10 PCPs who participated in Phase I of the project and 20 additional randomly-selected PCPs at LCHC. The 30 PCPs will participate in three onsite sessions at which they will be administered clinical cases for patient assessment and the development of a treatment plan, followed by an introduction and review of the VP (BETA)-prototype.

A survey will be used to rate the quality of the PCPs' treatment plans pre- and post-viewing of the VP (BETA)-prototype. Additionally, the semi-structured interviews and surveys used in Phase I of the study will be administered to the Phase II PCPs pre- and post-viewing of the VP to qualitatively assess the PCPs' perception of the VP BETA-prototype as a training and clinical tool. A followup phone call will collect qualitative data from the PCPs on the strengths and weaknesses of the VP and their recommended improvements to the VP (BETA)-prototype.

Successful development and implementation of the VP is intended to improve PCPs' assessment and treatment of trauma-related physical and mental health problems in highly-traumatized, culturally-diverse refugee patients. The VP will ultimately improve the quality of care for disadvantaged and culturallydiverse refugee patient populations who experience trauma-related physical and mental health issues.

Specific Aims:

  • Develop a final Virtual Patient (BETA)-prototype (from the existing (ALPHA)-prototype) that is perceived as an effective and engaging learning tool by primary care physicians. (Ongoing)
  • Test the ability of the Virtual Patient (BETA)-prototype to improve the primary care physicians' identification and screening of health and mental health problems in traumatized and culturallydiverse patients. (Ongoing)
  • Test the ability of the Virtual Patient (BETA)-prototype to improve the primary care physicians' treatment management plan of the health and mental health problems of traumatized diverse patients. (Ongoing)
  • Assess the feasibility of expanding the use of the Virtual Patient among primary care physicians at neighborhood health centers. (Ongoing)

2011 Activities: The study team at Massachusetts General Hospital and their collaborators at the Karolinska Institutet have met every other week by phone. The VP (ALPHA)-prototype was assessed and modified for Phase I testing. Ten PCPs from LCHC were recruited to participate in the Phase I pre- and post-testing of the VP and the existing VP (ALPHA)-prototype.

As last self-reported in the AHRQ Research Reporting System, project progress and activities are completely on track, and project budget spending is roughly on target.

Preliminary Impact and Findings: This project has no findings to date.

Target Population: Mental Health/Depression, Racial or Ethnic Minorities*: Bosnian Refugees

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Synthesis and Dissemination

* This target population is one of AHRQ's priority populations.

The Virtual Patient for Improving Quality of Care in Primary Healthcare - Final Report

Citation:
Mollica R. The Virtual Patient for Improving Quality of Care in Primary Healthcare - Final Report. (Prepared by Massachusetts General Hospital under Grant No. R21 HS020323). Rockville, MD: Agency for Healthcare Research and Quality, 2014. (PDF, 439.67 KB)

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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