Interview with the IT2 Project Team

Project Overview: The Identify, Teach and Treat (IT2) project is implementing screening for urinary incontinence at the time of pre-visit automated appointment confirmation in women presenting to primary care practice (PCP) annual visits. IT2 is being implemented in Northwestern Medicine, an integrated healthcare system. Women who screen positive for Urinary Incontinence (UI) are directed to a digital patient education and shared decision-making tool that populates patient treatment preferences into the patient chart for clinician review. For more information on IT2, read their project’s executive summary (PDF, 209 KB).

Stephen Persell, M.D., M.P.H., Division of General Internal Medicine, Department of Medicine, and Center for Primary Care Innovation, Institute for Public Health and Medicine, and Co-PI for the IT2 project responded to interview questions on behalf of the team. 

At a 30,000-foot view, what is most notable about your team’s approach to UI screening and treatment implementation within primary care? What strategies were central to your project?

To address the burden caused by urinary incontinence, we needed to get our patient and clinicians talking about it. Central to our approach was to make screening for this a part of regular clinic processes. We took advantage of pre-existing information technology and office workflows and added screening for urinary incontinence to them. 

What successes are you celebrating to date? 

A big milestone we reached in August was screening our 40,000th patient. As a result, we’ve identified more than 6,800 women with bothersome urinary incontinence among whom almost 4,000 wanted to learn about possible treatments. We are also excited that 36 different clinics within the health system have been willing to put UI screening into practice.

UI is often broached by the patient rather than the provider. How has your project been responsive to patient-driven needs?

We tried to make it as easy as possible for patients who may feel reluctant to bring up UI directly with their provider to report that they wanted help and to provide patients with a way to access reliable information to learn about UI and possible treatments. When patients indicated on the automated questionnaire that they wanted to learn about possible treatments, we sent them access to interactive educational content to help them become familiar with the range of treatment options available. The goal is to provide enough information so that someone with UI can decide what course of action to take right away and what options are available if initial treatment is not effective. We also wanted to be sensitive to the fact that not everyone with UI wants to address the topic immediately. We hope that by asking, we are letting people know that primary care is a place where they can seek help for this--whether the time is now or in the future.

Screening and treatment for UI are often not prioritized because they do not have payment or accountability performance measures linked to them. How did you incentivize practices to include this important clinical and quality of life issue in their workflows? How, if at all, did your approach to working with practices change over time?

We were able to put a measure in the electronic health record to show how well practices are screening for UI. We hope that by knowing UI screening is being measured, this will stir some clinicians and practices to do this in a reliable way. We are at a time when there is a trend towards reducing the number of performance measures used for external accountability, so it will be challenging to make UI screening part of an external incentive program. We do, however, hope that standard workflows and measurement will make it seem like another normal part of work of primary care. Over time, as more and more practices within our health system have adopted screening, we have taken the approach with new practices that this is just a normal thing to do.

What are some strategies you are implementing to ensure your intervention is sustained after the project ends?

A number of tools are hardwired into the electronic medical record, and we expect this will help sustain this work after the project ends. Some practices use direct reminders for rooming staff to screen, and we anticipate that will help sustain screening even when new staff join the practices. We also will continue the collaboration between primary care and urogynecology to make sure our patient and clinician-facing materials remain current and useful.

What has been your biggest lesson learned to-date?

This project highlighted some of the stresses that primary care offices are under. Practices that have been reluctant to implement the procedures to improve the detection and management of UI in primary care have never told us that addressing UI is a bad idea, just that adding another thing to their plate felt hard to do. Fortunately, once practices did implement screening it did not seem to be overwhelming. 

What advice would you have for primary care practices that may consider adopting interventions to screen and treat UI?

Being able to screen patients using an electronic questionnaire sent ahead of a patient’s preventive visit was a really effective way to boost screening for UI. It also seems like patients are more willing to report symptoms when asked through a question on their phone or computer compared to when a person asks in the office. If your practice is using any kind of automated patient questionnaires, you could consider adding UI screening to it.