Photo Credit: iStock.com/Jacob Wackerhausen

Dr. Brandi Fink discusses PALMS, a novel mobile platform she developed to streamline, increase, and improve alcohol use screening in primary care settings.

Excessive alcohol use is responsible for approximately 178,000 US deaths annually and increases the risk for cirrhosis, cardiovascular disease, infections, accidental deaths, dementia, and cancer.¹ In light of this, the US Preventive Services Task Force recommends primary care screening for unhealthy alcohol use in patients aged 18 and older—screening which a study published by the Journal of General Internal Medicine showed occurred during fewer than 3% of primary care visits.² To address this gap, Brandi Fink, PhD, University of Oklahoma College of Medicine Associate Professor, developed the Personal Alcohol Management System (PALMS), a mobile platform for the delivery of screening and brief interventions for alcohol misuse, designed to provide patients in primary care waiting rooms with immediate feedback on their alcohol consumption, offer risk-reducing strategies, and relay actionable recommendations to their primary care providers.

Physician’s Weekly (PW) spoke with Dr. Fink to learn more about how PALMS can assist primary care clinicians with identifying patients with an alcohol use disorder and intervening before the problem worsens.

PW: What inspired you to develop PALMS?

Dr. Fink: I’d been integrated into primary care for substance use treatment. Approximately 20% of primary care patients engage in hazardous or harmful drinking, and the majority of costs associated with alcohol-related issues arise from these individuals, not from patients with severe alcohol use disorders. I explained our screening protocol to our primary care providers, noting that if a patient screened at a certain level, they should let me know so I could come in and administer a brief intervention. I thought, “I’m going to get to intervene with all these patients at high risk for hazardous drinking,” but I was a young faculty member and naive to how these things worked. I heard absolute crickets. I was only referred to one patient—a patient with clear alcohol dependence who needed specialized treatment—but I came to appreciate and understand why this happens: Physicians have 15 to 20 minutes for a patient presenting for diabetes management, hypertension management, or another issue, so they feel uncomfortable bringing up [alcohol use] when they don’t have enough time to address it fully. They were also having difficulty identifying patients’ risk levels.

How did these insights lead to the development of PALMS?

During a monthly meeting at the Oklahoma Clinical and Translational Science Institute focused on commercialization and accelerating clinical innovation in patient care, I told my collaborators, “For 30 years, the public health approach to addressing high-risk drinking has been primary care screenings, brief interventions, and referrals to treatment, but now I understand why that doesn’t happen, so let’s do it for [primary care providers].”

Funding from a Small Business Innovation Research Award through the National Institutes of Health National Institute on Alcohol Abuse and Alcoholism (NIAAA) enabled us to develop and test PALMS. A biotechnology firm programmed the application to simulate a patient’s experience interacting with a trained provider in a primary care provider’s waiting room. We put PALMS on an iPad that patients were handed when they checked in for their appointment. While in the waiting room, patients completed the screening and immediately received personalized results and a brief intervention if they were identified as drinking at a high risk or harmful level. For example, “You are drinking at a high-risk level. Here’s what low-risk drinking is for someone your age and sex. This is what we recommend for you. This is what we’re going to communicate to your provider to support you in this.” Then PALMS sent the primary care provider the drinking level of the patient and actionable follow-up recommendations, such as, “Your patient screened at a low-risk drinking level, screen them again in a year,” or “They received a high-risk drinking level, screen them again in three months,” or “This patient needs to be referred to specialized assessment and treatment.”

How did PALMS perform in the initial phase of clinical trials?

The system resonated incredibly well with our three major stakeholders:

• Patients reported exceptional acceptability and usability, appreciating the nonjudgmental tone and intuitive software flow.
• Providers loved that PALMS provided clear next steps—alleviating them of that burden—and stated that PALMS improved their patient care.
• Healthcare administrators valued that the program generated revenue through billable services and allowed them to demonstrate effective management of high-risk patients to accrediting bodies.

What are the next steps for PALMS?

My experience with PALMS sparked an interest in venture commercialization, but I initially lacked confidence in taking the product to market. I was selected to participate in the MIT Bootcamp for Substance Use Disorder Ventures at the perfect time. My collaborators and I are now preparing a phase two clinical testing application to NIAAA, scheduled for submission in September. Our goal is to demonstrate non-inferiority to interventions delivered by actual providers. If successful, we can pursue FDA approval, positioning PALMS as a bonafide commercial product for sale and use in healthcare settings.

Could PALMS be adapted to screen for usage of other substances?

There is potential for expanding PALMS to cannabis use. The growing burden on primary care providers underscores the need for such innovations. Primary care providers are being asked to be a be-all, end-all for entry into identifying patient issues—whether that’s alcohol use, depression, or many, many other issues—and that’s a lot for a provider to do within 15 to 20 minutes with a patient. Our goal with PALMS is to unburden primary care providers. I want them to know that help is on the way.