Perinatal e-screening and clinical decision support: the Maternity Case-finding Help Assessment Tool (MatCHAT)

Abstract

INTRODUCTIONScreening tools assist primary care clinicians to identify mental health, addiction and family violence problems. Electronic tools have many advantages, but there are none yet available in the perinatal context. AIMTo assess the acceptability and feasibility of the Maternity Case-finding Help Assessment Tool (MatCHAT), a tool designed to provide e-screening and clinical decision support for depression, anxiety, cigarette smoking, use of alcohol or illicit substances, and family violence among pre- and post-partum women under the care of midwives. METHODSA co-design approach and an extensive consultation process was used to tailor a pre-existing electronic case-finding help assessment tool (eCHAT) to a maternity context. Quantitative MatCHAT data and qualitative data from interviews with midwives were analysed following implementation. RESULTSFive midwives participated in the study. They reported that MatCHAT was useful and acceptable and among the 20 mothers screened, eight reported substance use, one depression and five anxiety. Interviews highlighted extensive contextual barriers of importance to the implementation of maternity-specific screening. DISCUSSIONMatCHAT has potential to optimise e-screening and decision support in maternity settings, but in this study, use was impeded by multiple contextual barriers. The information from this study is relevant to policymakers and future researchers when considering how to improve early identification of common mental health, substance use and family violence problems.

Workload and workflow implications associated with the use of electronic clinical decision support tools used by health professionals in general practice: a scoping review

“…Many felt they tended to spend longer with patients when using the tool compared to usual consultations, but that this was because they were using the tool to provide better quality of care for their patients - One PN felt the consultation was lengthened, and another reported no change - Problems with tool functionality were perceived by some GPs as costing time. Some thought the tool itself slowed down their IT systems - Some felt the tool was distracting when the patient wasn’t attending for diabetes care Perception Impact on time : mixed views Driving perception : limited time in consultations, tool is time consuming and distracting, better quality care takes longer Wright et al 2020 [ 126 ] New Zealand To assess the acceptability and feasibility of the Maternity Case-finding Help Assessment Tool (MatCHAT), a tool designed to provide e-screening and clinical decision support for depression, anxiety, cigarette smoking, use of alcohol or illicit substances, and family violence among pre- and post-partum women under the care of midwives Condition of focus: Perinatal mental health Setting : Midwifery Tool : CDS for screening for antenatal and postnatal depression, anxiety, substance use and partner violence - Embedded/linked with EMR: No - Interruptive alert: No - User-driven: Clinician - Risk score: Unclear Mixed methods: Quantitative usage data + qualitative interviews with midwives MatCHAT usage data - numbers of screens completed - positive cases - participants who wanted help and the level of care recommended - survey ratings of acceptability, feasibility and utility Interviews - the MatCHAT prototype - midwives' knowledge - barriers to implementation Barriers to implementation - midwives unanimous that MatCHAT was ‘one more thing’ in their hectic work schedule, and this influenced the low uptake - The midwives who did not use MatCHAT thought that it would increase the length of appointments: ‘I was in conflict because I know I needed to ask those questions and MatCHAT would have been useful for that, but in another way, it was going to take up a large chunk of time.’ - midwives also worried that screening might ‘open a can of worms’ Perception Impact on time : mixed views Driving perception : - increase: heavy workload and limited time, worry that tool would increase time, might 'open a can of woms' - decrease: if used efficiently can cut overall time spent screening Wu et al 2013 [ 127 ] US To examine physicians' experiences of using MeTree, a computerized Family Health History CDS tool which includes risk stratification Condition of focus: Family health history Setting : Primary Care Tool : a CDS tool to collect ...…”

Digital screening for mental health in pregnancy and postpartum: A systematic review

“…I would definitely say the screening program is very good...” [Farzana] (p.e432-433) (Willey et al 2020 – Knowledge – Knowledge) (E) “I thought it was pretty easy” (p. 309) (Drake et al 2014 – Knowledge – Procedural knowledge) (E) Skills (N = 22) Skills of the Healthcare Professional and women Skills (N = 1) Skills development (N = 3) Competence (N = 0) Ability (N = 4) Interpersonal Skills (N = 10) Practice (N = 1) Skills assessment (N = 1) Enabler (E) Barry et al ( 2017 ); Doherty et al ( 2020 ); Doherty et al ( 2018 ); Guevara et al ( 2016 ); Johnsen et al ( 2018 ); Pineros-Leano et al ( 2015 ); Willey et al ( 2020 ); Wright et al ( 2020 ) Skills of the Healthcare Professionals and women to competently complete the digital screening or participate in professional development and education to further their knowledge “It probably builds the relationship between the parent and the provider more than it does anything else. They know you care about them too.” (p. 1865) (Guevara et al 2016 – Skills – Interpersonal Skills) (E) Social/professional role and identity (N = 40) Social professional role and identity of Healthcare Professional Professional identity (N = 0) Professional role (N = 29) Social identity (N = 0) Identity (N = 0) Professional boundaries (N = 2) Professional confidence (N = 10) Group identity (N = 0) Leadership (N = 0) Organisational commitment (N = 0) Enabler (E) Barrier (B) Barry et al ( 2017 ); Diez-Canseco et al ( 2018 ); Doherty et al ( 2020 ); Doherty et al ( 2018 ); Gance-Cleveland et al ( 2019 ); Guevara et al ( 2016 ); Johnsen et al ( 2018 ); Pineros-Leano et al ( 2015 ); Wright et al ( 2020 ) Social professional role and identity of Healthcare Professionals ability to do their job effectively, requirements of their job and belief that digital screening is part of their role Case manager, nurse: ‘… have all of our documentation done in one place, rather than double-documenting.’...…”

“…For PW3, sharing data related to her mental health would prove valuable only if her midwife “has received training, and when I’m talking about training, I’m talking about therapeutic training, about how to handle with care the data.” Both women and midwives highlighted the power-dynamics implicit in data sharing; “she knew so many things about me, I didn’t want to share everything [emphasis] with her” (M2). PW3 was keen to avoid a mode of interaction driven by scores and thresholds, “You scored 10 out of 10, good one!’ I don’t want to have this kind of chat with my midwife.” (p.5–6) (Doherty et al 2020 – Social/professional role and identity – Professional confidence) (B) Beliefs about capabilities (N = 4) Beliefs about capabilities of Healthcare Professional and women Self-confidence (N = 4) Perceived competence (N = 2) Self-efficacy (N = 0) Perceived behavioural control (N = 1) Beliefs (N = 1) Self-esteem (N = 0) Empowerment (N = 6) Professional confidence (N = 0) Enabler (E)/Barrier (B) Barry et al ( 2017 ); Doherty et al ( 2020 ); Doherty et al ( 2018 ); Dyurich and Oliver ( 2020 ); Pineros-Leano et al ( 2015 ) Beliefs about the capabilities of women and Healthcare Professionals to complete digital screening “It’s about empowering women to take responsibility for their mood and contacting us”; “It’s a risk assessment on whether that woman or client needs additional support” (p.2714) (Barry et al 2017 – Beliefs about capabilities – Empowerment) (E/B) Beliefs about consequences (N = 8) Beliefs about consequences for Healthcare Professional and women Beliefs (N = 1) Outcome expectancies (N = 2) Characteristics of outcome expectancies (N = 0) Anticipated regret (N = 4) Consequents (N = 3) Barrier (B) Barry et al ( 2017 ); Doherty et al ( 2020 ); Johnsen et al ( 2018 ); Wright et al ( 2020 ) Beliefs about the consequences for women and Healthcare Professionals with completing digital screening “I think you’d find it quite hard to be honest about that [the EPDS], if you knew your midwife was seeing it” (PW2), “because the language is quite clinical…I will think twice before replying to it” (PW3), “I don’t want them to think that I’ve got depression, because then that means it would go on my record, it might affect whether they believe I can look after my baby…it would affect my level of honesty I think, in reporting” (PW7). (p.5) (Doherty et al 2020 – Beliefs about consequences – Outcome expectancies; Anticipated regret) (B) Midwives to become “more focused on my ...…”

“…5) (p. e108) (Johnsen et al 2018 – Goals – Goals (distal/proximal) (B) Memory, attention and decision processes (N = 3) Memory, attention and decision processes for women and Healthcare Professionals Memory (N = 2) Attention (N = 0) Attention control (N = 0) Decision making (N = 1) Cognitive overload/tiredness (N = 0) Enabler (E) Doherty et al ( 2020 ); Guevara et al ( 2016 ); Pineros-Leano et al ( 2015 ) Use of digital screening to enhance memory and attention and assist in decision making for depression and anxiety assessment cut-off scores, referral and treatment services M3 envisioned the use of a mobile application as a means of overcoming cognitive limitations; “I might have forgotten what happened two weeks ago…if they would retrieve it and then say ‘Oh you mentioned this…this thing happened, do you want to share more?" (p.5) (Doherty et al 2020 – Memory, attention and decision processes – Memory (E) A mother in the study suggested that the app could be seen as a means of overcoming her cognitive limitations when recalling her emotions over the previous weeks Environmental context and resources (N = 69) Environmental context and resources required for digital screening Environmental stressors (N = 1) Resources/material resources (N = 46) Organisational culture/climate (N = 4) Salient events/critical incidents (N = 0) Person and environment interaction (N = 17) Barriers and facilitators (N = 0) Barrier (B) Enabler (E) Barry et al ( 2017 ); Diez-Canseco et al ( 2018 ); Doherty et al ( 2020 ); Doherty et al ( 2018 ); Drake et al ( 2014 ); Dyurich and Oliver ( 2020 ); Gance-Cleveland et al ( 2019 ); (2016); Guevara et al ( 2016 ); Johnsen et al ( 2018 ); Pineros-Leano et al ( 2015 ); Willey et al ( 2020 ); Wright et al ( 2020 ) Environmental context and resources required to complete digital screening, including available and accessible technology (e.g., computer, tablet, mobile phone), privacy, room, staff, finances, organisational support, pressure, time and any difficulties or special requirements needed for women in order to complete screening Some days I was screening and I was really excited to do it, but when I was with the third pregnant woman ...…”

Research and education in clinical training

“…It has been trialled for different types of user. 11,12 In this issue we publish a report of the development of VeCHAT, the tool targeted for use by military Veterans and developed in partnership with the Ministry of Defence and Veterans Affairs. 13 We hope you find plenty to interest, stimulate and challenge you in this issue of the Journal.…”