Capturing Social and Behavioral Domains and Measures in Electronic Health Records Phase 2 (2014) / Chapter Skim
Currently Skimming:
4 Measures Reviewed for Each Candidate Domain
4 Measures Reviewed for Each Candidate Domain
Pages 127-226
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 127... ...
The logistical challenges for routine, harmonized measurement tools are significant, but as described in earlier chapters, opportunities exist toward increasing standardization. Toward meeting this goal, the committee applied criteria 3 to 6 to the 17 candidate domains, along with their subdomains, in reviewing and evaluating measures of those domains.
|
From page 128... ...
5. Sensitivity, that is, if patient discomfort regarding revealing personal information is high and there are increased legal or privacy risks.
|
From page 129... ...
Depressive symptoms or social support are examples of constructs that are assessed through responses to questions. See Box 4-2 for information on instruments and scales.
|
From page 130... ...
The relationship between the domain concept, its subdomains, the metrics, and instruments that provide measurements on the common metric is shown in Figure 4-1. For example, the domain of physical activity has several subdomains (mobility/motion, flexibility, and strength)
|
From page 131... ...
In some instances, the committee chose to use one or two questions from a full set of validated questions. They did this in order to make the domain measures feasible in a clinical setting.
|
From page 132... ...
born or non-U.S. born Education Employment Financial resource strain: Food and housing insecurity Psychological Domain Measures Health literacy Stress Negative mood and affect: Depression and anxiety P sychological assets: Conscientiousness, patient engagement/activation, optimism, and self-efficacy Behavioral Domain Measures Dietary patterns Physical activity Tobacco use and exposure Alcohol use
|
From page 133... ...
, and living conditions (e.g., financial resource strain)
|
From page 134... ...
The committee believes that more detailed questions about sexual practices are better asked as part of the clinical interview. Common Metric There is not a commonly accepted metric for these measures at this time.
|
From page 135... ...
Other Measures Reviewed There are other commonly used measures (to whom a person is attracted regardless of how they identify themselves or who they have sex with) , but these questions appear to be less critical for medical care.
|
From page 136... ...
* = lowest rating)
|
From page 137... ...
. The question on sexual orientation is similar to the question reviewed by the committee on sexual identity.
|
From page 138... ...
¨ Some other race (with fill in option) Common Metric The U.S.
|
From page 139... ...
Because of these considerations the committee rated the measures of the race/ethnicity domain as follows in Table 4-2. Limitations of Measure Limitations of the U.S.
|
From page 140... ...
* = lowest rating)
|
From page 141... ...
The committee suggests using only question 12 (Where was this person born?
|
From page 142... ...
Because of these considerations, the committee rated the measure as follows in Table 4-3. Limitations of Measure As stated earlier, the clinical care team should be sensitive to individuals whose immigration status is questionable.
|
From page 143... ...
Born Lack of Sensitive Committee Standard Measure Information or Judgment of the and Freely Available Usefulness Feasible Patient Discomfort Measure (*
|
From page 144... ...
The committee evaluated the education measures originally developed by the U.S. Census and expanded by the MacArthur Research Network on SES & Health (MacArthur Research Network on SES & Health, 2008)
|
From page 145... ...
These two measures will be useful for population health management. Education levels correlate with many health indicators, particularly as a health determinant and in their links to SES and health literacy, making it useful to capture them on a clinical level (Commission to Build a Healthier America, 2009; Woolf and Braveman, 2011; Woolf et al., 2007)
|
From page 146... ...
* = lowest rating)
|
From page 147... ...
Standard measures used in national surveys such as the National Health and Nutrition Examination Survey (NHANES) are useful but were judged by the committee to be too long and complex to be included in the EHR.
|
From page 148... ...
Specific Populations For children and adolescents, parental employment status should be obtained. Other Measures Reviewed The committee gave serious consideration to the inclusion of other work and occupational measures, including characterization of type of occupation and other physical and psychosocial exposures at work for those employed.
|
From page 149... ...
* = lowest rating)
|
From page 150... ...
Financial Resource Strain: Food and Housing Insecurity Financial resource strain is a composite of both subjective evaluation of economic difficulties and specific sources of strain, such as food insecurity or housing insecurity (Kahn and Pearlin, 2006)
|
From page 151... ...
. As stated earlier, financial resource strain has various composites, food insecurity and housing insecurity being two of those components.
|
From page 152... ...
Positive respondents were then asked "whether or not they had to move in with friends or family because they had no other choice." Common Metric There is no common metric for financial resource strain. Ratings of Measures by Committee The single question for overall financial resource strain is accepted, freely available, and shows a strong association with current health status.
|
From page 153... ...
Other Measures Reviewed In addition to the CARDIA and NHANES questions for evaluating financial resource strain, two other measures the committee reviewed were the BEST Index and the Elder Index developed by Wider Opportunities for Women (WOW, 2014)
|
From page 154... ...
* = highest rating, Domain Measures *
|
From page 155... ...
. Further, limited health literacy is associated with poor health outcomes (IOM, 2009)
|
From page 156... ...
As a result, adverse health effects of low health literacy can be reduced not just by identifying the needs and capacity of the individual patient but also by assuring the clarity of communication with all patients no matter what their literacy level. All patients deserve clear communication, not just those deemed to have low health literacy levels.
|
From page 157... ...
Other Measures Reviewed The committee considered other scales, specifically, REALM-66, REALM-Short Form (SF) , Short Assessment of Health Literacy for Spanish-speaking Adults (SAHLASA)
|
From page 158... ...
* = lowest rating)
|
From page 159... ...
Given the evidence of the importance of adverse early life exposures and links to adversity and stress, the committee examined the Adverse Childhood Experiences (ACE) tool.
|
From page 160... ...
To obtain a measure of current stress, the committee evaluated a single question developed by Elo et al.
|
From page 161... ...
(2003) is freely available and has been assessed by the committee to be highly feasible for inclusion in the EHR and it is moderately sensitive in nature, potentially causing patient discomfort.
|
From page 162... ...
* = highest rating, Domain Measures *
|
From page 163... ...
Identification and Description of Measures For an initial patient screen for depression the committee considered the Patient Health Questionnaire (PHQ) for depression, which is a commonly used screener in diverse clinical settings.
|
From page 164... ...
I felt unhappy 8. I felt hopeless Common Metric Both the PHQ-2 and the PROMIS-8b short form can be scored on the PROMIS Depression T-scale, which serves as the common metric for depressive symptoms.
|
From page 165... ...
Because of these considerations, the committee rated the measures as follows in Table 4-9. Limitations of Measure The primary limitation of the PHQ-2 is a concern about the management challenges that the health system may face in following up on what may be a substantial number of patients who have a positive depression screen.
|
From page 166... ...
* = highest rating, Domain Measures *
|
From page 167... ...
. Other Measures Reviewed The committee considered other widely used and validated scales, specifically, the CES-D scale and the WHO-K6 or K10 scales.
|
From page 168... ...
I felt anxious Common Metric Like other PROMIS scales, PROMIS anxiety scores are T-scores with a standard deviation of 10 developed based on large community and clinical samples. The PROMIS Anxiety T-score has a mean of 50 (centered on the U.S.
|
From page 169... ...
There is no PROMIS measure for children younger than 5 years of age. Other Measures Reviewed The GAD-2 short form instrument, derived from GAD-7, had a sensitivity of 86 percent for generalized anxiety disorder, 76 percent for panic disorder, 70 percent for social anxiety disorder, along with reliable specificity (83 percent to 81 percent)
|
From page 170... ...
* = lowest rating)
|
From page 171... ...
: I see myself as someone who: ¨ Tends to be lazy ¨ Does a thorough job Common Metric There is no current common metric for conscientiousness. Ratings of Measure by Committee Use of the measure of conscientiousness, based on the NeuroticismExtraversion-Openness (NEO)
|
From page 172... ...
* = lowest rating)
|
From page 173... ...
. Other Measures Reviewed There is a two-item conscientiousness scale from the 10-item Personality Inventory.
|
From page 174... ...
Other Measures Reviewed Measures related to the PAM have been developed for patients with specific diseases, but no validated measures of patient activation that would be appropriate for the diverse types of patients served by EHRs have been published. Optimism Identification and Description of Measure The prevailing measure of optimism is the Life Orientation Test-Revised (LOT-R)
|
From page 175... ...
* = most, Domain Measure *
|
From page 176... ...
Common Metric There is not a commonly accepted metric for optimism at this time. Ratings of Measure by Committee This scale is rated as low in patient burden, high in ease of administration, and unlikely to cause stigmatization.
|
From page 177... ...
* = lowest rating)
|
From page 178... ...
Specific scales have been developed and validated for other behaviors (e.g., smoking cessation [Etter et al., 2000] , nutrition-related or dietary patterns [Anderson et al., 2000]
|
From page 179... ...
The NIH Toolbox measure of generalized self-efficacy has normative data that could be used to develop a common metric for self-efficacy among adults. Ratings of Measures by Committee There is no standard measure of self-efficacy for specific behaviors.
|
From page 180... ...
* = highest rating, Domain Measures *
|
From page 181... ...
Dietary Patterns Dietary patterns (summary measures of food consumption) are often examined in the research setting to capture their associations with health, and they are increasingly used in the clinical setting to guide lifestyle counseling.
|
From page 182... ...
. Common Metric There is no common metric for dietary patterns at this time.
|
From page 183... ...
* = lowest rating)
|
From page 184... ...
This is an emerging area of science. Other Measures Reviewed Measures of specific dietary patterns (e.g., the eight-item Starting the Conversation screen, the Dietary Approaches to Stop Hypertension diet, and the Mediterranean diet)
|
From page 185... ...
and is more practical for clinical settings. The two-question Exercise Vital Sign has adequate reliability for screening the physical activity level of a population (Coleman, 2012)
|
From page 186... ...
Patient compliance can be a problem, and the cost of accelerometers presents another barrier to routine use in clinical settings. Common Metric Clinically relevant groupings of activity behaviors have been developed using METs as a measure of physical activity intensity.
|
From page 187... ...
* = highest rating, Domain Measures *
|
From page 188... ...
. Other Measures Reviewed The International Physical Activity Questionnaire has a short form with nine questions.
|
From page 189... ...
codes: • Current every day smoker • Current some day smoker • Former smoker • Never smoker • Smoker, current status unknown • Unknown if ever smoked • Heavy tobacco smoker • Light tobacco smoker The ways in which tobacco counseling and treatment are handled by EHRs remains to be settled but was considered out of scope for this committee. Identification and Description of Measure Smoking status questions, lifetime and current, have been asked on the NHIS for almost half a century and are used to assess progress toward achieving the Healthy People 2020 objectives.
|
From page 190... ...
Other Measures Reviewed Other measures assess degree of dependence on nicotine. All have acceptably high levels of validity and reliability and have been shown to be
|
From page 191... ...
* = lowest rating)
|
From page 192... ...
. The Nicotine Dependence Syndrome Scale (NDSS)
|
From page 193... ...
Identification and Description of Measure Among multi-question scales measuring alcohol misuse and dependence that have acceptably high reliability and validity, the Alcohol Use Disorders Identification Test Consumption (AUDIT-C) is a three-question instrument, modified from the AUDIT 10-question instrument.
|
From page 194... ...
Ratings of Measure by Committee The AUDIT-C questions are freely available to administer in clinical settings, and it is a useful health tool in monitoring patients who are alcohol dependent or who have problem drinking behaviors. The AUDIT-C question takes approximately 1 minute to complete, making it feasible and practical for a patient to complete before a clinical visit.
|
From page 195... ...
* = lowest rating)
|
From page 196... ...
Other Measures Reviewed The committee reviewed several measures for alcohol use, including the single screening question, "On any single occasion during the past 3 months, have you had more than five drinks containing alcohol? ," which can detect at-risk drinking and current alcohol use disorders (Fleming, 2004/2005; Taj et al., 1998)
|
From page 197... ...
. INDIVIDUAL-LEVEL SOCIAL RELATIONSHIPS AND LIVING CONDITIONS DOMAIN MEASURES Social Connections and Social Isolation Social relationships have been identified as a major psychosocial risk factor for health, and they have been identified as potential resources or buffers mitigating the impact of other risk factors for health, such as stress, and facilitating recovery from acute and chronic diseases (Cassel, 1976; Cobb, 1976)
|
From page 198... ...
Common Metric There is no common metric for social connection and isolation at this time. 4 Marital status information is collected in the demographic section of NHANES that includes the following options: married, widowed, divorced, separated, never married, and living with partner.
|
From page 199... ...
However, the committee felt the four-question NHANES III measure was appropriate for use in all adults. Other Measures Reviewed Although similar evidence exists for the relation of measures of social support and of loneliness to health, it is not as strong and consistent as that for social integration versus isolation, nor is there as clearly a consensual measure that is easily administered (Holt-Lunstad et al., 2010; Steptoe et al., 2013)
|
From page 200... ...
* = lowest rating)
|
From page 201... ...
Health care costs are generally higher for those experiencing intimate partner violence, and undetected and untreated intimate partner violence can lead to poor health outcomes. Screening for intimate partner violence in health care settings is one of the eight preventive health services now covered in new health plans without requiring a copayment, coinsurance, or deductible5 (HRSA, 2012)
|
From page 202... ...
. Common Metric There is not a common metric for intimate partner violence at this time.
|
From page 203... ...
; however, assessments of intimate partner violence for adolescents or children are not currently available. Other Measures Reviewed The committee reviewed other assessments of risk of violence; however, most lacked standards for validity.
|
From page 204... ...
* = lowest rating)
|
From page 205... ...
, but it lacked a clinical cutoff. NEIGHBORHOODS AND COMMUNITIES DOMAIN MEASURES Neighborhood and Community Compositional Characteristics A large body of work has used measures of neighborhood socioeconomic characteristics to investigate the impact of neighborhood contexts on health (Diez-Roux and Mair, 2010)
|
From page 206... ...
Because census tracts were at least initially defined to be approximately homogeneous in socioeconomic characteristics, and because they are used in many analyses as proxies for neighborhoods, the committee suggests using census tract measures. The median household income measured in current U.S.
|
From page 207... ...
An example of how to collect patient address in a standard way is listed below: • ouse Number + Directional (such as North, South, etc.) + H Street Name • City • State • Zip Code + 4-digit extension Common Metric There is not a common metric for neighborhood and community compositional characteristics at this time.
|
From page 208... ...
* = highest rating, Domain Measures *
|
From page 209... ...
However, it is expected that the availability of geocode information in the EHR will stimulate further research on the value of these measures and may justify including additional measures in the EHR in a systematic way in the future. The committee hopes that in the future, variables related to compositional characteristics of the neighborhood and measures reflecting contextual characteristics, such as hazards and resources in the physical and social environment, will be standardized and routinely collected and thus able to be linked to all patient records.
|
From page 210... ...
Financial Resource Strain Overall Financial Resource *
|
From page 211... ...
* = lowest rating)
|
From page 212... ...
= least) Health Literacy Chew et al.
|
From page 213... ...
* = lowest rating)
|
From page 214... ...
(4 Q) Exposure to Violence Intimate Partner Violence: *
|
From page 215... ...
2014. Health literacy universal precautions toolkit.
|
From page 216... ...
2013. Culture in the context of health literacy: Update.
|
From page 217... ...
2004. Health literacy: Universal precautions needed.
|
From page 218... ...
2006b. Preventing intimate partner violence, sexual violence, and child maltreatment.
|
From page 219... ...
2000. Assessment of intimate partner violence among high-risk postpartum mothers: Concordance of clinical measures.
|
From page 220... ...
2008. Plain language: A promising strategy for clearly communciating health information and improving health literacy.
|
From page 221... ...
2006. The health literacy of America's adults: Results from the 2003 National Assessment of Adult Literacy (NCES 2006 483)
|
From page 222... ...
Presentation to the Committee on the Recommended Social and Behavioral Domains and Measures for Electronic Health Records: Washington, DC: IOM. MESA (Multi-Ethnic Study of Atherosclerosis)
|
From page 223... ...
2009. Intimate partner violence screening tools.
|
From page 224... ...
2002. Association of health literacy with diabetes outcomes.
|
From page 225... ...
to identify intimate partner violence: A diagnostic accuracy study in general practice. BMC Family Practice 8(1)
|
From page 226... ...
2013. Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.