Photo Credit: Drazen Zigic

Switching from paper to tablets may improve pediatric screenings for health-related social needs such as nutrition and caregiver mental health concerns.

Findings published in Pediatrics highlight the benefits of shifting from paper-based screening for health-related social needs (HRSN)/caregiver mental health concerns (CMHC) to tablet-based screening.

Michelle C. Gorecki, MD, MPH, and colleagues found that families were more likely to disclose HRSN/CMHC when using electronic devices, resulting in more referrals to social work and multi-layered partnership services.

According to the study results, the American Academy of Pediatrics and the Academic Pediatric Association both advocate for screening and addressing HRSN and CMHC in pediatric settings, emphasizing their importance for promoting health equity, particularly among marginalized communities.

Previous research indicates that caregivers are more comfortable disclosing sensitive information, such as food insecurity and household violence, through non-verbal methods like paper or electronic tablets. However, no previous research has directly compared HRSN/CMHC disclosures between paper and electronic methods.

Dr. Gorecki and colleagues aimed to assess differences in disclosure rates between these modalities and examine whether increased need identification through electronic screening would lead to higher referral rates to social work and medical-legal partnerships (MLP).

This study was conducted through a retrospective review of EHR data from 3 academic pediatric primary care practices, 2 in urban settings (Sites A and B) and one in a suburban area (Site C). The practices serve predominantly underserved populations, with a significant proportion on public insurance and identifying as Black.

The caregivers of patients aged 18 or younger completed a HRSN/CMHC questionnaire during well-child visits. The screening was paper-based from February to December 2018, and the transition to electronic tablets began in January 2019 and extended to December 2019.

Disclosure Rates Increase With Electronic Screening

The analysis included 16,151 patients with paper-based HRSN/CMHC screenings and 13,019 patients with electronic screenings.

Overall, 11% of paper-based screenings identified one or more needs compared with a quarter (26%) of electronic screenings (P<0.001).

Using interrupted time series analyses, Dr. Gorecki and colleagues found that two of three practices significantly increased the odds of need disclosure with electronic (OR, 3.0; 95% CI, 2.5-3.6) versus paper (OR, 1.7; 95% CI, 1.2-2.4) screening. According to the study results, higher rates of HRSN/CMHC disclosure with the switch to electronic screening mediated increased referrals to social work/MLP.

All three practices saw an increase in disclosure rates following the move from paper to electronic screening, though the magnitude varied: Site A had the highest increase (OR, 4.24), followed by Site B (OR, 2.18) and Site C (OR, 1.54).

Additionally, more patients disclosed multiple HRSN/CMHC categories, particularly food insecurity and CMHC, while disclosures of housing concerns and difficulties affording medication decreased, mainly influenced by Site A’s results.

Dr. Gorecki and colleagues found that the increase in HRSN/CMHC disclosures was associated with increased referrals to support services. After switching to electronic screening, social work referrals rose from 4.1% to 5.1%, and referrals to MLP increased from 1.2% to 1.8%.

Among those who disclosed HRSN/CMHC, the proportion referred to social work jumped from 38% to 57%, and MLP referrals increased from 67% to 83%. Mediation analyses confirmed that the higher referral rates were partially mediated by the increased disclosure rates resulting from the electronic screening.

The indirect effect was statistically significant across all sites, indicating that electronic screening led to up to 1.6 times higher odds of social work referrals and up to 2.2 times higher odds for MLP referrals. However, the direct effects of electronic screening on referrals were only significant at Site A, suggesting site-specific factors may have influenced the outcomes.

Improving Screening Completion in Pediatric Visits

According to Dr. Gorecki and colleagues, this increased disclosure and referral rate is believed to be linked to the sense of privacy and ease associated with electronic screening. The findings underscore the potential of electronic modalities to improve patient outcomes by enhancing the identification of needs and facilitating timely interventions.

“We found that health-related social needs/caregiver mental health concerns disclosure rates significantly increased with electronic tablet screening compared with paper screening,” the researchers wrote. “Our study suggests that clinicians consider a transition to electronic HRSN/CMHC screening, given its link to increased identification of HRSN/CMHC and subsequent connection to services.”

Key Takeaways

• Switching from paper to electronic screening for social needs and mental health led to the identification of more needs: 11% with paper versus 26% with electronic screening
• More patients disclosed multiple types of health-related social needs /caregiver mental health concerns with electronic screening, especially food insecurity
• Referrals to social support services also increased with electronic screening, including social work and medical-legal partnerships
• The increased disclosure and referral rates are likely due to the sense of privacy and ease associated with electronic screening, according to study investigators