Clinical
`
`Computing
`
`Systems
`Interactive Voice Response
`in Clinical Research
`and Treatment
`
`James
`
`C. Mundt,
`
`Ph.D.
`
`cry
`the
`
`F rom Bell’s
`
`first
`to
`currently
`been
`have
`Interactive
`systems,
`for
`
`for
`crisis
`tele-
`in
`
`or
`now
`
`to Watson
`many
`assistance
`available,
`help-lines
`serving
`people
`phones
`voice
`response
`need.
`a rapidly
`expanding
`(IVR)
`automated
`acquisition
`technology
`of
`information,
`repre-
`and
`dispersal
`sent
`the
`convergence
`of computer-au-
`tomated
`interviewing
`with
`touch-
`tone
`telephone
`service.
`IVR applica-
`tions
`for
`routing
`telephone
`calls
`accessing
`banking
`services
`are
`commonplace.
`benefits
`Potential
`research
`clinical
`begun
`recently
`As budgets
`realized.
`delivery
`treatment
`efficiency
`greater
`use
`ofIVR
`quality,
`expand.
`continue
`use
`describes
`and
`in research
`and
`substance
`
`for
`have
`and
`and
`require
`sacrificing
`tions
`will
`column
`technology
`of psychiatric
`orders.
`
`systems
`IVR
`of
`treatment
`and
`explored
`to be
`research
`for
`continue
`without
`applica-
`This
`IVR
`of
`treatment
`use
`
`to
`the
`
`dis-
`
`to
`
`diagnosis
`and
`Assessment
`using
`IYR applications
`assess
`Computers
`can reliably
`valid
`symptoms
`and
`provide
`noses
`Several
`computerized
`
`(6).
`
`clinical
`diag-
`as-
`
`use
`
`data
`These
`.001).
`p <
`.67,
`findings
`support-
`to other
`of
`computers
`to
`assess
`symptoms.
`Such
`comput-
`diagnostic
`interviews
`are
`now
`for
`touch-tone
`telephone
`
`(kappa
`contribute
`ing
`the
`psychiatric
`erized
`available
`administration.
`
`of
`
`IVR ap-
`appeared
`
`have
`
`dai-
`
`discussions
`detailed
`More
`plications
`in research
`elsewhere
`(1,2).
`for obtaining
`An IVR program
`alcohol
`consump-
`self-reports
`of
`ly
`has
`been
`demonstrated
`to pro-
`tion
`valid
`data,
`permitting
`analyses
`vide
`of alcohol
`use
`patterns
`that
`differen-
`tiate
`dependent
`from nondependent
`drinkers
`otherwise
`matched
`on quan-
`thy-frequency
`measures
`use
`(3,4).
`of
`Data
`collection
`using
`IVR systems
`be
`beginning
`to
`used
`for
`investigat-
`ing
`other
`conditions,
`such
`as
`eating
`disorders
`and
`impaired
`psychomotor
`and
`cognitive
`performance
`(5).
`
`is
`
`that
`smoking,
`
`treatment
`for
`IVR applications
`clock,
`IVR pro-
`Accessible
`around
`the
`patient-specific
`in-
`grams
`provide
`can
`treatment,
`en-
`formation,
`self-help
`couragement,
`reinforcement,
`and
`on
`request.
`With
`confiden-
`support
`unique
`personal
`tiality
`protected
`by
`identification
`numbers
`and
`pass-
`words,
`patients
`interacting
`with
`IVR
`that
`is
`systems
`provide
`information
`to
`used
`tailor
`current
`and
`in-
`future
`teractions.
`As
`goals
`are
`achieved
`or
`setbacks
`encountered,
`context-rele-
`vant
`messages
`are
`provided.
`of
`interaction
`may
`be most
`type
`eficial
`in
`treating
`frequently
`ring
`behaviors
`intrude
`life,
`such
`as
`drinking,
`sive-compulsive
`behaviors,
`pression.
`pro-
`cessation
`smoking
`A voluntary
`an IVR system
`advertised
`using
`gram
`through
`work
`site
`health
`promotions,
`media,
`and
`radio
`found
`that
`print
`571
`smokers,
`35 percent
`quit
`smoking
`while
`using
`the
`program,
`and
`14 per-
`cent
`remained
`abstinent
`six months
`their
`initial
`call
`(12). For
`smokers
`after
`who
`called
`system
`five
`or more
`the
`times,
`these
`percentages
`increased
`and
`substantially
`(68
`percent
`22
`per-
`cent,
`respectively),
`suggesting
`that
`patients’
`willingness
`to use
`sys-
`is
`tems
`a
`strong
`predictor
`IVR
`treatment
`effectiveness.
`An IVR application
`for
`tients
`with
`obsessive-compulsive
`order
`allows
`patients
`to develop
`implement
`a treatment
`plan
`by
`
`This
`ben-
`occur-
`daily
`obses-
`or
`de-
`
`on
`
`of
`
`such
`of
`
`treating
`
`pa-
`dis-
`and
`guid-
`
`the
`including
`Scale,
`the Hamilton
`the Yale-Brown
`Scale,
`and
`Scale,
`
`Hamilton
`Depres-
`Obsessive
`the Liebowitz
`re-
`have
`been
`in-
`are
`being
`drug
`trials
`(8).
`of
`these
`instru-
`to monitor
`pa-
`used
`feedback
`to
`clini-
`
`(7)
`
`sessments,
`Anxiety
`sion
`Scale,
`Compulsive
`Social
`Anxiety
`and
`viewed
`recently
`clinical
`corporated
`into
`IVR implementations
`ments
`are
`being
`tients
`and
`provide
`(9).
`cians
`such
`interviews,
`Computerized
`(10) and Symptom-Dri-
`PRIME-MD
`System
`for
`yen
`Diagnostic
`Primary
`been
`developed
`to di-
`(11),
`have
`Care
`axis
`I disorders
`corn-
`DSM-IV
`agnose
`in primary
`care
`patients
`monly
`found
`implemented
`as
`IVR
`have
`been
`and
`A study
`of 200
`patients
`applications.
`using
`PRIME-MD,
`implemented
`via
`IVR technology,
`found
`a high
`corre-
`spondence
`between
`the
`PRIME-MD
`the
`IVR system
`with
`diagnoses
`made
`and
`those
`obtained
`using
`the
`Struc-
`tured
`Clinical
`Interview
`for DSM-IV
`
`as
`
`of IVR systems
`Use
`for data collection
`IVR systems
`man-
`and
`obtaining
`for
`over
`advance
`data
`a major
`are
`aging
`tele-
`previous
`methods.
`Touch-tone
`collec-
`phones
`permit
`24-hour
`data
`tion,
`removing
`previous
`limitations
`related
`to distance
`or temporal
`avail-
`of
`study
`staff. Automatic
`data
`ability
`collection
`by
`computers
`eliminates
`to
`transcription
`or
`inter-
`errors
`due
`viewer
`mistakes
`and
`facilitates
`opti-
`data
`management
`procedures.
`mal
`
`at
`scientist
`is a research
`Di: Mundi
`the
`Dean
`for Health,
`Research,
`Foundation
`Education,
`2711
`Allen
`Boulevard,
`and
`Middleton,
`Wisconsin
`53562
`(e-mail,
`MundtJainesC@ssmhcs.com).
`John
`H.
`Greist, M.D.,
`is editor
`column.
`
`this
`
`of
`
`PSYCHIATRIC SERVKES
`
`. May
`
`1997
`
`Vol.
`
`48
`
`No.5
`
`611
`
`CFAD VI 1017-0001
`
`

`

`of
`ex-
`
`condition
`improved
`
`exposure
`them through
`mg
`situ-
`and
`(13). Mea-
`al-prevention
`procedures
`symp-
`sures
`of obsessive-compulsive
`functioning,
`toms,
`work
`social
`and
`and
`indicat-
`symptoms
`of depression
`12-week
`a
`ed
`improvement
`during
`making
`study
`of 40 patients.
`Patients
`greater
`use
`of
`the
`system
`experienced
`the most
`improvement;
`77 percent
`those
`who
`completed
`or more
`two
`and
`posure
`ritual-prevention
`sessions
`reported
`that
`their
`was
`or
`“much”
`“very much”
`at
`the
`end of
`the
`study.
`obtained
`been
`has
`Similar
`success
`IVR
`program
`treating
`for
`with
`an
`(14).
`mild
`to moderate
`depression
`was
`Again,
`a positive
`relationship
`and
`found
`between
`program
`use
`treatment
`outcome.
`Of
`individuals
`ten
`voluntarily
`making
`or more
`calls
`over
`to the
`IVR system
`the
`12-week
`study
`period,
`72 percent
`showed
`a 50
`percent
`reduction
`in their
`Hamilton
`Depression
`Scale
`scores,
`whereas
`only
`30 percent
`of
`those making
`few-
`er
`ten
`showed
`such
`im-
`than
`provement.
`
`calls
`
`of IVR
`The future
`touch-tone
`to
`access
`Widespread
`growing
`famil-
`service
`telephone
`and
`IVR systems
`in the popula-
`iarity
`with
`tion at large will
`contribute
`to contin-
`ued
`and
`expanded
`use
`of
`IVR
`appli-
`treatment.
`cations
`in
`research
`and
`Bringing
`subjects
`study
`person-
`and
`nel
`together
`often
`constrains
`the
`Se-
`lection
`ofstudy
`sites
`to densely
`popu-
`lated
`locations,
`which
`can
`limit
`the
`generalizability
`of
`results.
`Interrater
`for
`reliability
`is a persistent
`concern
`data
`par-
`raters,
`obtained
`by
`human
`ticularly
`for multisite
`studies
`in which
`consistent
`training
`feedback
`and
`are
`of validated
`difficult.
`Administration
`research
`instruments
`using
`IVR pro-
`grams
`addresses
`of
`these
`issues.
`both
`Automated
`assessment
`diag-
`and
`nostic
`information,
`such
`as
`that
`ob-
`tamed
`by
`the
`IVR
`PRIME-MD,
`could
`be obtained
`routinely
`from pa-
`tients
`before
`their
`scheduled
`appoint-
`ments
`used
`for directing
`and
`further
`assessment
`when
`patients
`and
`inquiry
`seen
`face
`to
`face.
`Computerized
`are
`use,
`instructions
`for
`medication
`as ef-
`which
`have
`been
`shown
`to be
`(15),
`fective
`as
`personal
`instruction
`implemented
`as an IVR ap-
`could
`
`be
`
`612
`
`and made
`Such
`programs
`on
`staff
`time
`efficient
`use
`
`24 hours
`available
`reduce
`de-
`can
`facilitate
`and
`limited
`
`of
`
`re-
`
`plication
`a day.
`mands
`more
`sources.
`examples
`treatment
`the
`Although
`the
`potential
`for
`above
`illustrate
`stand-alone
`IVR-administered
`thera-
`for this
`py,
`the
`greatest
`potential
`tech-
`as an adjunct
`to clini-
`nology
`may
`cal
`interaction.
`The
`process
`of recov-
`and
`health
`maintenance
`requires
`ery
`efforts
`by patients.
`IVR applica-
`daily
`tions
`allow
`patients
`self-report
`to
`progress
`and
`establish
`computerized
`records
`of
`achievement.
`Reports
`setbacks
`could
`be used
`for facilitating
`patient-practitioner
`discussion
`dur-
`ing face-to-face
`sessions.
`Applications
`currently
`being
`developed
`to per-
`are
`mit
`practitioners
`to
`design
`cus-
`tomized
`scripts,
`recorded
`their
`in
`voice,
`addressing
`the
`individual
`own
`needs
`and
`therapeutic
`goals
`of specif-
`ic patients.
`sen-
`will disclose
`individuals
`Many
`that
`to a computer
`sitive
`information
`discuss
`reluctant
`to
`they
`would
`be
`another
`person
`(6). Because
`with
`IVR program
`permits
`such
`interac-
`the
`tion
`from
`of
`one’s
`safety
`own
`of
`home,
`some
`the most
`socially
`stig-
`matizing
`issues,
`such
`as sexual
`abuse,
`HIV risk-related
`behaviors,
`and alco-
`hol
`and
`abuse,
`might
`be most
`drug
`amenable
`to
`IYR-mediated
`screen-
`ing,
`assessment,
`and
`therapy.
`Permit-
`ting
`anonymous
`access
`to IVR appli-
`cations
`addressing
`highly
`sensitive
`is-
`sues
`might
`bridge
`current
`barriers
`that
`prevent
`patients
`from
`seeking
`help.
`Callers
`could
`be
`reassured,
`edu-
`cated
`about
`sources
`of
`support
`in the
`to make mi-
`and
`helped
`community
`tial
`steps
`toward
`recovery.
`
`primary
`
`deter-
`
`the
`be
`will
`programs
`success.
`their
`of
`minant
`IVR technology
`clini-
`provide
`can
`administrators
`and
`cians,
`researchers,
`data
`of gathering
`a new method
`with
`pa-
`to
`information
`and
`presenting
`a touch-
`and
`place
`tients
`time
`any
`any
`This
`in-
`is available.
`tone
`telephone
`outcome
`assessments
`teraction
`allows
`of
`therapeutic
`and
`development
`have
`not
`previously
`proaches
`that
`can
`The
`technology
`been
`feasible.
`extend
`clinical
`practice,
`strengthen
`ad-
`methods,
`and
`enhance
`research
`quali-
`support
`of
`service
`ministrative
`ty and value, which
`goals
`should
`be
`#{149}
`all health
`innovations.
`care
`
`ap-
`
`of
`
`References
`
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`An application
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`JS, et al:
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`Meth-
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`JC, Searles
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`Psy-
`
`Continues
`
`on page
`
`623
`
`be
`
`of
`
`an
`
`Conclusions
`This
`this mean?
`all
`What
`does
`advocate
`replacing
`does
`not
`services
`with
`IVR
`patient
`Rather,
`services
`could
`tions.
`hanced-cost-effectively-by
`technology.
`priate
`use
`of
`this
`and
`feedback
`tent
`information
`to
`patients
`by
`computers
`vided
`an efficient
`telephone
`affords
`resources.
`of
`extending
`staff
`research
`ences
`IVR
`with
`indicate
`ment
`programs
`ingness
`of
`individuals
`
`column
`current
`applica-
`be
`en-
`appro-
`Consis-
`pro-
`via
`means
`Experi-
`treat-
`and
`the will-
`use
`these
`
`that
`to
`
`PSY(cid:1)IllATRIC
`
`SERYKES #{149}May
`
`1997
`
`Vol.
`
`48
`
`No.
`
`5
`
`CFAD VI 1017-0002
`
`

`

`service
`frequent
`for
`difference
`The major
`health
`system
`during
`the
`introduction
`of
`tem.
`These
`plementation
`intervention
`inpatient
`lation
`
`results
`of
`this
`produced
`utilization
`offrequent
`
`decrease.
`users
`in our mental
`that
`time was
`triggers
`sys-
`the
`suggest
`that
`im-
`system
`for
`early
`a reduction
`of
`among
`the
`popu-
`service
`users.
`
`be
`
`of
`
`in-
`stay
`and
`
`that
`
`way
`of
`
`and
`for
`led
`and
`
`re-
`(12-
`have
`may
`quantifiable
`re-
`and
`system
`in the
`The
`an
`the
`when
`time
`
`un-
`ser-
`
`Discussion
`conclusions
`and
`for the
`effectiveness
`One
`explanation
`system
`in reducing
`ofthe
`triggers
`patient
`admissions
`length
`and
`may
`that
`the
`system
`tracking
`clinical
`reviews
`led
`to improvements
`the
`in
`the
`overall
`functioning
`of
`man-
`Local
`mental
`health
`system.
`involve-
`agers
`reported
`increased
`in
`team
`ment
`by
`private
`providers
`communica-
`reviews,
`more
`effective
`in cases
`where
`tion
`among
`providers
`a
`single
`con-
`many
`agencies
`serve
`sumer,
`and more
`intensive
`fo-
`cused
`treatment
`planning
`fre-
`quent
`service
`users,
`which
`to
`more
`effective
`interventions
`bet-
`ter
`outcomes.
`The
`idea
`contact
`increased
`intensive
`through
`with
`consumers
`reduce
`may
`case
`management
`documented
`cidivism
`is well
`system
`15). The
`triggers
`provided
`a
`systematic,
`way
`to
`focus
`the
`attention
`care
`sources
`of
`the managed
`on a selected
`group
`ofpatients
`early
`stages
`of decompensation.
`triggers
`system
`has
`also
`provided
`easy
`for
`staff
`to
`prioritize
`needs
`various
`consumers
`competing
`demands
`on
`staff
`and
`energy
`are made.
`trig-
`the
`of
`A major
`positive
`result
`in-
`gers
`system
`the
`increased
`was
`in
`volvement
`private
`providers
`by
`re-
`treatment
`planning
`clinical
`and
`mental
`views.
`In the
`past,
`the
`public
`gain-
`health
`system has had difficulty
`ing
`access
`to the
`time
`and
`resources
`of private
`providers
`who
`are
`not
`der
`contract
`for
`the
`provision
`of
`vices.
`triggers
`The
`for best
`teria
`of
`dimensions
`J oint
`Commission.
`teria
`for efficacy
`increased
`scrutiny
`planning
`for
`consumers
`
`cri-
`nine
`the
`cri-
`
`system
`the
`meets
`in the
`practices
`care
`outlined
`by
`It meets
`the
`because
`it produces
`and
`treatment
`who may
`
`be
`
`From
`mance:
`Terrace,
`brook
`creditation
`1994
`
`Principles
`Ill, Joint
`of Healthcare
`
`to Practice.
`Oak-
`on Ac-
`Commission
`Organizations,
`
`11. Klegon
`network
`provement
`359-363,
`
`JCAHO
`DA:
`accreditation
`project.
`1997
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`mental
`as a performance
`Psychiatric
`Services
`
`care
`im-
`48:
`
`J, Wasmer
`D, Witheridge
`12. Dincin
`community
`of
`assertive
`Impact
`hospital
`on the use
`of state
`days.
`Hospital
`and Community
`44:833-838,
`1993
`
`TE et al:
`treatment
`inpatient
`bed-
`Psychiatry
`
`13. Dietzen
`be-
`Relationship
`GR:
`Bond
`LL,
`tween
`outcome
`contact
`and
`manager
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`frequently
`hospitalized
`psychiatric
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`Hospital
`and Community
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`try44:839-843,
`1993
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`JH: Frequent
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`CLINICAL COMPUTING
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`10. Spitzer
`et
`K,
`JB, Kroenke
`RL, Williams
`of a new procedure
`for diagnosing
`Utility
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`primary
`care:
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`JAMA 272:1749-
`1000
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`
`al:
`
`11. Broadhead
`WE,
`et
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`Leon AC, Weissman
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`13. Baer
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`
`14. Osgood-Haynes
`et al:
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`L, Greist
`D, Baer
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`assess-
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`Use
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`of depression.
`Poster
`ment
`and
`treatment
`presented
`at
`the
`annual
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`that
`
`deterio-
`a psychiatric
`experiencing
`appropri-
`process
`is also
`ration.
`The
`ate because
`plan-
`it allows
`treatment
`im-
`to the
`consumer’s
`ning
`directed
`meets
`The
`system
`mediate
`needs.
`timeli-
`availability,
`the
`criteria
`for
`efficiency
`and
`ness,
`effectiveness,
`are
`provid-
`reviews
`because
`clinical
`events
`soon
`trigger
`ed
`for
`screened
`plan
`re-
`and
`the
`after
`the
`event,
`reduces
`un-
`review
`sults
`from
`the
`and
`crisis
`necessary
`hospitalizations
`is a coop-
`stays.
`Because
`the
`process
`service
`erative
`venture
`among
`of hospi-
`providers,
`reduces
`the
`risk
`the
`con-
`talization,
`and
`includes
`planning,
`the
`sumer
`treatment
`and
`safety,
`re-
`goals
`continuity,
`of
`are met. We
`hope
`spect
`caring
`and
`study
`will
`further
`de-
`that
`continued
`fine
`the
`advantages
`of
`the
`triggers
`the
`system
`and
`that
`results
`reported
`#{149}
`here may
`replicated.
`
`in
`
`be
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`623
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`CFAD VI 1017-0003
`
`