Barriers and Facilitators to Implementing One Key Question® in a Midwifery Practice within a University Health System

Prevention of unintended pregnancy and promotion of health prior to conception are widely accepted approaches to lowering maternal and infant mortality. Despite the likely substantial return on investment, routine screening for pregnancy intention is not typically incorporated into the care of reproductive- age women during all healthcare encounters. With nearly half of all births in the United States unintended, and the increased risks for the mother and infant associated with unintended pregnancies, the need to establish clinical practices aimed at accurately identifying and referring women to appropriate reproductive health services is essential. One Key Question®(OKQ), developed by the Oregon Foundation for Reproductive Health (OFRH), was introduced as simple approach to encourage primary care providers to routinely ask women about their reproductive health intentions. This promising strategy encourages providers to ask all women of reproductive-age, regardless of the primary reason for their visit, "Would you like to become pregnant in the next year?" By developing a simple question to initiate the conversation and an algorithm to guide recommendations, OFRH created a program for health care providers to facilitate preconception counseling for all women capable of reproduction and promote contraceptive utilization for women that do not desire pregnancy. If used routinely, universal pregnancy intention screening and appropriate referral could result in significant reductions in unintended pregnancy rates and increased uptake of preconception care for reproductive-age women. The aim of this project was to improve knowledge of CNMs within BCHC about OKQ and increase knowledge about the barriers and facilitators to OKQ integration in order to develop a strategy for successful integration into the BCHC clinical practice. Taking time to review clinical data, talk with key stakeholders, and identify the key barriers and facilitators to implementation of OKQ screening was critical to creating an informed implementation plan. This process revealed a lack of consistency in conducting, documenting, and billing for preconception and contraception counseling. It was discovered that all levels of healthcare providers felt standardization of pregnancy intention screening and counseling through the use of OKQ, along with implementation into the EMR, would increase ease of use, improve consistency, and help to overcome the number one barrier which was lack of time. The Data obtained through this process was then utilized to develop an informed implementation plan designed to overcome barriers and bolster facilitators and will likely improve the success of implementation.

BARRIERS AND FACILITATORS TO IMPLEMENTING ONE KEY QUESTION® Barriers and Facilitators to Implementing One Key Question® in a Midwifery Practice within a University Health System Krista L. Labbe Project Chair: Ana Sanchez-Birkhead Content Expert: Sara Simonsen University of Utah 
 In Partial Fulfillment of the Requirements for the Doctor of Nursing Practice Page 1 BARRIERS AND FACILITATORS TO IMPLEMENTING ONE KEY QUESTION® Page 2 Abstract Prevention of unintended pregnancy and promotion of health prior to conception are widely accepted approaches to lowering maternal and infant mortality. Despite the likely substantial return on investment, routine screening for pregnancy intention is not typically incorporated into the care of reproductive-age women during all healthcare encounters. With nearly half of all births in the United States unintended, and the increased risks for the mother and infant associated with unintended pregnancies, the need to establish clinical practices aimed at accurately identifying and referring women to appropriate reproductive health services is essential. One Key Question®(OKQ), developed by the Oregon Foundation for Reproductive Health (OFRH), was introduced as simple approach to encourage primary care providers to routinely ask women about their reproductive health intentions. This promising strategy encourages providers to ask all women of reproductive-age, regardless of the primary reason for their visit, "Would you like to become pregnant in the next year?" By developing a simple question to initiate the conversation and an algorithm to guide recommendations, OFRH created a program for health care providers to facilitate preconception counseling for all women capable of reproduction and promote contraceptive utilization for women that do not desire pregnancy. If used routinely, universal pregnancy intention screening and appropriate referral could result in significant reductions in unintended pregnancy rates and increased uptake of preconception care for reproductive-age women. The aim of this project was to improve knowledge of CNMs within BCHC about OKQ and increase knowledge about the barriers and facilitators to OKQ integration in order to develop a strategy for successful integration into the BCHC clinical practice. Taking time to review clinical data, talk with key stakeholders, and identify the key barriers and facilitators to implementation of OKQ screening was critical to creating an informed implementation plan. This process revealed a lack of consistency in conducting, documenting, and billing for preconception and contraception counseling. It was discovered that all levels of healthcare providers felt standardization of pregnancy intention screening and counseling through the use of OKQ, along with implementation into the EMR, would increase ease of use, improve consistency, and help to overcome the number one barrier which was lack of time. The Data obtained BARRIERS AND FACILITATORS TO IMPLEMENTING ONE KEY QUESTION® Page 3 through this process was then utilized to develop an informed implementation plan designed to overcome barriers and bolster facilitators and will likely improve the success of implementation. BARRIERS AND FACILITATORS TO IMPLEMENTING ONE KEY QUESTION® Page 4 Introduction Health care provider inquiry of women's reproductive health intentions is inconsistent and lacks a systematic approach to provide appropriate guidance (M'hamdi, van Voorst, Pinxten, Hilhorst, and Steegers, 2017). One Key Question®(OKQ), developed by the Oregon Foundation for Reproductive Health (OFRH), was introduced as a groundbreaking program created to encourage primary care providers to routinely ask women about their reproductive health intentions (Bellanca & Hunter, 2013). This promising strategy encourages providers to ask all women of reproductive-age, regardless of the primary reason for their visit, "Would you like to become pregnant in the next year?" By providing a simple question to initiate the conversation and an algorithm to guide recommendations; OFRH created a program for health care providers to conduct preconception counseling for all women capable of reproduction and recommend contraceptive options for women who want to avoid pregnancy (Allen, Hunter, Wood, & Beeson, 2017). Bellanca and Hunter (2013) argue that if used routinely, OKQ could be the intervention needed to make significant reductions in unintended pregnancy rates and increase the number of women provided preconception care (PCC). Problem Description Prevention of unintended pregnancy and PCC are widely accepted approaches to lower maternal and infant mortality through the improvement of several health indicators and pregnancy outcomes (Beckmann, Widmer, & Bolton, 2014). Despite the likely substantial return on investment, routine screening for pregnancy intention are not standard for all reproductive-age women during all healthcare encounters (Boggess & Berggren, 2015). With nearly half of all births in the United States being unintended and the increased risks associated with unintended pregnancy, there is an essential need to establish clinical practices aimed at accurately identifying necessary reproductive health services for women (Bellanca & Hunter, 2013). National health care reform has increased the attention on reproductive health services as part of the core preventative services that should be available to all women (Bellanca & Hunter, 2013). This has led to a push to understand the potential impact of routine pregnancy intention screening and PCC (Floyd, Johnson, Owens, Verbiest, Moore, & Boyle, 2013). OKQ provides a program to guide health care providers as they work with women to optimize health prior to pregnancy and provide effective contra- BARRIERS AND FACILITATORS TO IMPLEMENTING ONE KEY QUESTION® Page 5 ception for those who wish to delay or prevent pregnancy. Therefore, over 30 professional organizations, including the American Congress of Obstetricians and Gynecologists (ACOG), have enthusiastically supported OKQ as a means to address the clear need for routine screening (Bellanca & Hunter, 2013). To date, OKQ has not been sufficiently evaluated to understand if routine integration of OKQ into clinical care actually helps make women healthier, reduces the number of unplanned pregnancies, or improves pregnancy outcomes. The OKQ strategy was created for primary care providers to remove the divide between well woman or problem-focused visits and reproductive care. Today, more women are seeking their certified nurse midwife (CNM) to meet all their primary care needs. Consequently, successful implementation and evaluation of this proactive screening tool in this setting may be beneficial. The first step of this project was to collect data and conduct interviews with key stakeholders to become familiar with current BirthCare HealthCare (BCHC) practice patterns and thoughts about integrating routine pregnancy screening into clinical practice. To better understand the barriers and facilitators to implementation of OKQ in a CNM practice, providers first had to be trained about OKQ. The training was followed by interviews of advanced practice nurses and clinic managers to learn about the barriers and facilitator to OKQ implementation. This information was then used to develop a strategy for successful integration of OKQ into BCHC clinical practice. While time consuming, taking time to understand barriers and facilitators to implementation and development of a plan to overcome those barriers and bolster the facilitators will likely improve the success of implementation. According to Watt, Sword, and Krueger (2005) no matter how convincing a program may be, it cannot be expected to change health care practice if the facilitating and inhibiting factors are not adequately addressed. Available Knowledge According to MacDorman, Declercq, Cabral, & Morton (2016) maternal death rates are rising and little progress has been made in reducing infant and fetal mortality, signifying that the paradigm of focusing on the health of a pregnancy after conception (prenatal care) is inadequate. Additionally, inequalities between women marginalized by race, ethnicity and income are growing (MacDorman, et al., 2016). According to Bellanca and Hunter (2013) maternal risk factors, health conditions, and behaviors that most significantly impact maternal and fetal outcomes are best modified, and may only be modified, prior to pregnancy. This is due to the fact that even if a woman has her first prenatal appointment in the first BARRIERS AND FACILITATORS TO IMPLEMENTING ONE KEY QUESTION® Page 6 trimester, the fetal organs are already mostly formed so interventions will have little to no effect on preventing adverse outcomes and/or birth defects. The American College of Obstetrics and Gynecology (2005) recommend that PCC should not only address pregnancy planning for women who seek medical care specifically in anticipation of a planned pregnancy but also target all women capable of reproduction for education and screening to identify potential maternal and fetal risks before and between pregnancies. Despite several organizations publishing PCC guidelines, M'hamdi, et al. (2017) described the lack of familiarity with PCC among future parents, arguing that this is in part attributable to health professionals' inexperience with PCC recommendations. This lack of familiarity with PCC is further complicated by the diverse views of the roles and responsibilities health care providers possess to address reproductive health needs. PCC is also burdened by the lack of a standardized, comprehensive program to provide guidance appropriate for each woman's reproductive intention (M'hamdi, et al., 2017). The Center for Disease Control and Prevention (2015) argue that efforts to help reach the Healthy People 2020 goal to improve pregnancy planning, spacing, and preventing unintended pregnancy should include increased access to contraception, particularly the highly effective LARC methods, and a rise in correct and consistent use of contraceptive methods for those who are sexually active but wish to avoid or delay pregnancy. Allen, Hunter, Wood, and Beeson (2017) suggest that for women who choose not to become pregnant or are ambivalent in their pregnancy intent, OKQ provides an opportunity for referral or provision of counseling and contraceptive care. They explain that the adoption of OKQ will require a shift in the cultural norm which define the onset of pregnancy as the appropriate starting point for attention to infant and maternal health. Fortunately, discussions about reproductive intentions within health care settings has been recognized as an important strategy to help shift this cultural norm in order to reduce unintended pregnancy and improve pregnancy outcomes by ensuring optimal health prior to conception (Callegari, Aiken, Dehlendorf, Cason & Borrero, 2017). Rationale The theoretical framework of the ACE Star Model of Knowledge Transformation was utilized to guide the improvement of provider knowledge and better understand the barriers and facilitators to OKQ integration. This model is a theoretical framework developed by Kathleen R. Stevens (2012) at the Acad- BARRIERS AND FACILITATORS TO IMPLEMENTING ONE KEY QUESTION® Page 7 emic Center for Evidence Based Practice at the University of Texas Health Science Center. It was created as a systematic way to understand how knowledge is synthesized and facilitate its translation of evidence into practice. The five phases of this model are depicted on a five-pointed star to demonstrate the process of knowledge transformation that must take place for healthcare providers to integrate evidence into practice. The five areas include discovery research, evidence summary, translation into guidelines, practice integration, and the evaluation of process and outcome (Stevens, 2012). The discovery research phase of this project included interviews with BCHC leaders as well as gathering data about current clinical practices related to contraception and PCC. Additionally, a literature review was conducted to gather knowledge about pregnancy intention screening, promoting change within a CNM practice, as well as methods to effectively provide education and evaluate changes in knowledge among health care providers. The objective of this stage was to identify research outcomes and the need for change in clinical practice (Stevens, 2012). An evidence summary was created to summarize the knowledge gained during this phase to facilitate the integration of this information into interviews, education, and the pre- and post-education questionnaires. Translation into guidelines was completed through the communication of the knowledge gained in the evidence summary and OKQ education materials. According to Stevens (2012), clinical practice guidelines generally state the costs, advantages, and disadvantages of the intervention to inform provider practice. Thus, the education module included these topics to advance provider knowledge and to ensure implementation barriers and facilitators were adequately addressed. Education was conducted to support informed clinical decisions through education modules presented to midwives. The outcome of this project is a comprehensive integration plan to guide successful integration into BCHC clinical practice. Process outcome and evaluation was completed through pre- and post-education questionnaires to identify whether the education module was an effective tool to increase knowledge and comfort with implementing OKQ into clinical practice. Dissemination will be facilitated through poster presentations and manuscript submission. Specific Aims The goal of this project was to improve knowledge of CNMs within BCHC about OKQ and increase knowledge about the barriers and facilitators to OKQ integration in order to develop a strategy for BARRIERS AND FACILITATORS TO IMPLEMENTING ONE KEY QUESTION® Page 8 successful integration into the BCHC clinical practice. This project did not intend to change current recommendations for contraceptive or PCC; the intention was to understand how to best implement the program to encourage BCHC providers to inquire about the reproductive intentions of all women of reproductive-age, at all visits, regardless of the primary reason for the visit. Thus, this project set the foundation for the future integration of OKQ into the clinic flow and electronic medical record (EMR) for all six BCHC clinic locations. The purpose of this article is to share knowledge gained about the OKQ screening program and discuss the barriers and facilitators to the integration of OKQ into a Midwifery and Women's Health practice setting. Methods Context The Midwifery and Women's Health faculty practice at the University of Utah, BCHC, is made up of fifteen Advanced Practice Registered Nurses. They provide obstetric, gynecologic, and primary care to women across the lifespan to meet the needs of women throughout the region while providing clinical practice opportunities for faculty and students. Births are completed at the University of Utah hospital in Salt Lake City and out-patient services are provided at six locations across the Salt Lake Valley. According to CNM Celeste Thomas, BCHC clinical director, the OKQ initiative aligns well with the BCHC practice mission and is a simple, realistic program that could significantly improve preconception care and decrease the unintended pregnancy rate. As a collaborative partner, CNM Thomas, supported the participation of clinical staff in OKQ training, group discussions, and interviews to work towards the integration of OKQ into clinical practice. Collaboration with Dr. Sara Simonsen from the University of Utah College of Nursing, provided the expertise and guidance required to gain IRB approval and bring this project to fruition. The knowledge and support from Rachael Hemmert, research assistant, ensured validity throughout. Additional collaborating organizations included the Utah Department of Health OKQ certified trainer, Nickee Palacios, and the Obstetric and Gynecologic (OB/GYN) Clinic Director, Dr. Jennifer Trauscht-Van Horn. The support and assistance of collaborating members on this project was instrumental to the success of its success. Interventions BARRIERS AND FACILITATORS TO IMPLEMENTING ONE KEY QUESTION® Page 9 Electronic medical record and billing data were gathered and analyzed to understand the current practice patterns of BCHC. This inquiry was developed with the assistance of key stakeholders (KS), content experts, and personnel within the University of Utah enterprise data warehouse. This information helped to glean how often PCC and contraception counseling was occurring with women of reproductive age. Further insight was also gained about how and where PCC and contraception counseling was documented and whether it was billed as such. After obtaining consent, an education session was conducted with eighteen CNMs by a OKQ trained facilitator from the Utah Department of Health. Change in knowledge and confidence was assessed with pre- and post-education questionnaires. The pre- and post-questionnaires were developed based on input from KS and content experts. Questionnaires were matched by number to allow the identity of the participants to remain anonymous while linking pre/post data. Pre- and post-education responses were entered into REDCap and analyzed in Stata to provide descriptive statistics about provider knowledge change and the likelihood of integrating OKQ into their clinical practice. Interviews were developed with the guidance of KS and content experts to understand the perceptions about pregnancy intention screening and OKQ. Perceived barriers and facilitators to the implementation of OKQ was also solicited. Interviews were audio recorded and conducted after consent was collected with four key stakeholders, to include the BCHC clinical director and three clinic managers. Additionally, five CNMs, and eleven Medical Assistants (MA) were interviewed to ensure insight was gained from all level of the patient care team. The CNMs and MAs selected to be interviewed were all clinicians that provide primary care to women during their reproductive years, 15 - 49 years of age. Due to the anticipated delay with integrating OKQ into the EPIC electronic medical record (EMR), several meetings with EPIC personnel and key stakeholders were also completed. An IRB application was submitted and approved by the University of Utah prior to conducting interviews and education sessions. The project chair and content expert reviewed and approved all findings. Study of the Interventions The aim of this study was not to directly assess the impact of the use of the routine pregnancy intention screening program, OKQ. The aim was to understand the barriers and facilitators to OKQ implementation into a health system to inform a successful implementation plan and to establish benchmarks BARRIERS AND FACILITATORS TO IMPLEMENTING ONE KEY QUESTION® Page 10 for comparison after implementation. Preconception and contraception ICD 10 codes and specific field inquiry in EPIC was utilized for data retrieval. The organization and analysis of data was a collaborative effort of a team led by Mike Newman. Education of eighteen CNMs was completed by a OKQ certified trainer from the Utah Health Department of health, Nickee Palacios. Questionnaires were completed before and after this training to assess knowledge and confidence change. The validity of the pre- and post-tests was established through consensus of a multi-disciplinary team before sessions were conducted. Interviews were conducted with five CNMs, eleven MAs, and four key stakeholders/clinic managers. All interviews were recorded and completed with research assistant, Rachael Hemmert. The validity of the interviews was also established through consensus. There was one competing project identified. This project conducted by the March of Dimes in May of 2017 trained four BCHC providers. While this project did not hinder the ability to assess barriers and facilitators to OKQ implementation, it did place a burden on the ability for subsequent education to show a significant knowledge change in those health care providers. Measures Knowledge and confidence change related to the OKQ education conducted by the Utah Department of Health OKQ trainer was assessed through analysis of pre- and post-education surveys with the Wilcoxon Signed Rank Test. This test was chosen due to having paired pre- and post- tests, the data was not ordinal, and also not equally distributed or non-parametric. Interviews where stopped when no new themes were identified in terms of barriers, facilitators, or ideas about how to integrate OKQ. Analysis Pre- and post-education questionnaire responses were entered into REDCap and analyzed in the data analysis software, Stata, to obtain, visualize, and make inferences of collected data. Thus, this analysis assisted in the production of descriptive statistics about provider knowledge change and the likelihood of integrating OKQ into clinical practice. These descriptive statistics were then utilized to organize the qualitative analysis of the transcripts obtained from interviews and focus group discussions. Ethical Considerations BARRIERS AND FACILITATORS TO IMPLEMENTING ONE KEY QUESTION® Page 11 The study protocol for One Key Question® for Utah Women received an IRB exemption determination, Category 11, from the University of Utah on November 9, 2017. No other ethical considerations identified. Results In 2017, the University of Utah health system cared for 258,861female patients and 117,850 of those women were of reproductive age. Certified Nurse Midwives within this system saw 4,827 patients totaling 16,853 office visits. OB/GYN providers saw an additional 21,000 female patients of reproductive age. Seventy-five percent of this patient population identified as white or caucasian and the second most common race identified was "other" at twelve percent. Approximately ten percent of the patients resided out of state with Idaho, Wyoming, and Nevada being the most frequent states identified. English was the most common language spoken, representing ninety percent of the population, and Spanish was the chosen language of five percent of the population. Systemwide, seventy-one percent of women of reproductive age had commercial Utah insurance, fourteen percent were self-pay and ten percent were covered by Utah Medicaid. The patient population utilizing CNM care varied slightly with seventy-four percent utilizing Utah Commercial insurance, twelve percent were self-pay, and another twelve percent utilized Utah Medicaid. Systemwide billing data analysis revealed twenty-one percent of women of reproductive age were provided PCC while thirty percent of women cared for by CNMs were provided this service. Contraception care was billed for ten percent of the reproductive aged women systemwide vs. twenty-four percent of CNM visits. Billing for emergency contraception (EC) systemwide and CNMs was equally insignificant due to the occurrence in less that 0.04% of the patient population. The education sessions with eighteen CNMs demonstrated a statistically significant knowledge and comfort level change as evidenced by pre- and post-education assessments with knowledge (p= 0.04) and confidence (p=0.07). Thus, we were able to reject the null hypothesis that pre and post test scores were not different and conclude the training was effective in improving provider knowledge and confidence in the ability to utilize OKQ. Survey data collected during the CNM education session indicated seventeen of the eighteen participants were interested in exploring ways to integrate OKQ into their clinical practice. Feedback during BARRIERS AND FACILITATORS TO IMPLEMENTING ONE KEY QUESTION® Page 12 this session identified the need for an additional focus group with obstetric and gynecologic (OB/GYN) specialists who partner with the BCHC clinical practice at the University of Utah. Prior to this focus group discussion, a brief overview of the routine pregnancy intention screening program OKQ, with follow-up preconception and contraceptive care guided by the OKQ algorithm was conducted. Fifteen OB/ GYNs attended this training and engaged in the focused discussion. Seven also provided written feedback. Of the seven that completed the written surveys, five said they were interested in exploring ways to integrate OKQ into their clinical practice. One significant difference noted between the CNM and OB/ GYN feedback was one hundred percent of CNMs indicated the screening and recommendations should be completed solely by the provider, while nearly half of the OB/GYNs preferred to involve the MA in the screening process. Interestingly, one hundred percent of MAs felt they should be involved in the screening process. Interviews with four KSs, five CNMs, and eleven MAs providing assistance for both CNM and OB/GYN providers were completed. The original plan to interview five KSs was modified due to reaching consensus after the first four interviews. Eleven MAs were interviewed, surpassing the original objective to interview five MAs, due to the interest and participation level being higher than anticipated. While only one MA indicated she was currently completing routine pregnancy intention screening, only one said she was not comfortable discussing this topic with patients. Additional feedback from the MAs indicated strong support for the implementation of OKQ and they embraced both asking the screening question and conveying the women's response to the provider verbally and/or through documentation in the EMR. Survey and interview data indicated that all but one KSs viewed lack of time as the biggest barrier to implementing routine pregnancy intention screening and one hundred percent of KSs answered that more training and/or inclusion in the EMR would help facilitate implementation of routine pregnancy intention screening. Seventy-five percent also thought a reminder system would also be helpful. Medical assistants viewed lack of time (70%) and lack of interest (50%) as the largest barriers to implementing pregnancy intention screening. Ninety percent of MAs stated that inclusion of the screening in the EMR would be the best facilitator toward implementation with a reminder system (60%) being the next best facilitator. Data obtained from CNM and OB/GYN providers will be collectively discussed as BARRIERS AND FACILITATORS TO IMPLEMENTING ONE KEY QUESTION® Page 13 "providers" throughout the remainder of this report. Seventy percent of providers stated lack of time (70%) and lack of interest (50%) were the largest barriers to implementing routine pregnancy intention screening. Providers surveyed also believed that inclusion of the screening in the EMR (90%) and a reminder system (60%) would be the best facilitators in implementing pregnancy intention screening. Key stakeholders reported one hundred percent of women capable of reproduction receive contraception counseling in their clinics and this education was always completed by the providers although it was at times augmented by other clinic staff. Over ninety percent of providers indicated they conduct contraceptive counseling with all women of childbearing age and the others indicated it was done only when contraception was the primary focus of the visit. Components of this counseling included a screening for their desire to become pregnant, current contraception use, satisfaction with current method, and compliance of use. Also, while most contraception methods were available at all clinic sites, the ability to provide cervical cap and diaphragm fitting was provider dependent and female sterilization procedure capabilities were not available at all locations. Of note, male sterilization procedures are not performed by those interviewed. Contraception topics not consistently addressed were EC options, covered by sixty percent, and prescribing EC, which was covered by forty percent. In a follow-up question three providers said they never recommend EC as a routine part of contraceptive services, one said they always did, and the others were inconsistent with this recommendation. All providers reported that it was rare for them to prescribe and/or document EC in the medication list during counseling and also indicated they rarely receive requests for emergency contraction on an urgent basis. PCC was also reported by KSs as being consistently provided at all clinic locations. The component KSs identified as being included in all PCC was medication review and other components identified as almost always included were recommendation of prenatal vitamin with folic acid, screen for chronic health conditions, birth spacing recommendations, screen for prior pregnancy complications, fertility awareness, and psychosocial concerns. Provider reports of PCC counseling varied slightly from the KS reports with sixty-four percent of providers conducting PCC with all patients of reproductive age and the remaining providers indicated it was only completed if that was the reason the appointment was scheduled. The topics covered also varied slightly with one hundred percent of providers reporting they BARRIERS AND FACILITATORS TO IMPLEMENTING ONE KEY QUESTION® Page 14 screened for chronic conditions and recommended a prenatal vitamin with folic acid. Most providers indicated they recommended over-the-counter prenatal vitamins and others indicated they asked the patient whether they preferred a prescription. Other findings of topics covered by providers were similar to KS reports. All providers felt comfortable conducting routine pregnancy intention screening and thought it could increase the provision of preconception counseling/screening. Over seventy percent of providers indicated they already conduct routine pregnancy intention screening with all patients. Remaining providers indicated it was dependent on the patients chief complaint but claimed the topic was addressed during all annual exams. Sixty-four percent of providers stated they always document this counseling and and the others identified that they sometimes or rarely documented the counseling. The location providers documented the counseling also varied but the most frequently identified location was within the progress note. Readiness of clinics and staff to integrate routine pregnancy intention screening was not consistent across clinic locations and varied from just getting started to having identified champions and buy-in from all staff. Facilitators identified by all clinical staff included acceptance of pregnancy intention as an important screening tool and adding the algorithm to the EMR to standardize documentation. A universally recognized barrier was that lack of time to document pregnancy intention may impede screening in the clinic setting. This identification for the need to streamline the documentation of routine screening led to several meetings with representatives from the EPIC EMR team at the University of Utah to facilitate future integration. Despite ongoing collaboration with EPIC personnel, challenges with identifying the optimal location to integrate OKQ into the EMR remain and warrant further investigation. A tool suggested to bolster OKQ implementation was additional training for utilization of the algorithm once integrated into the EMR and the preference for this training was presentations during staff meetings. An additional need was identified was education materials addressing preconception and contraception care in Spanish and Arabic to help facilitate patient education for the largest non-english speaking populations within the University of Utah health system. A barrier recognized universally was cultural and/or religious issues with sex and reproductive health in their patient population. Some of the cultural barriers discussed were reproductive health beliefs associated with religion, the weight of reproductive BARRIERS AND FACILITATORS TO IMPLEMENTING ONE KEY QUESTION® Page 15 decisions and outcomes primarily placed on women, and the belief that women do not have the capability or right to plan their pregnancies. To help address cultural barriers additional training about completing pregnancy intention screening and guidance was requested for addressing this topic with immigrant/ refugee population, LGBTQ, pre-menopausal women, adolescents, parents, and men. Discussion Summary University of Utah health system data analysis revealed a lack of consistency in conducting, documenting, and billing for preconception and contraception counseling. Additionally, reports of how often and what patients are offered preconception and contraceptive counseling varies by provider and clinic location. Despite reports from most providers that they already routinely provide care recommended by the OKQ program, all endorsed that standardization of pregnancy intention screening and counseling along with implementation into the EMR would increase ease of use, improve consistency, and help to overcome the lack of time barrier. Unfortunately, the optimal location to document this screening has not been established. While the opinions of whether MAs should be involved in the screening process varied among providers and KSs, MAs supported both asking the screening question and conveying the women's response to the provider verbally and/or through documentation in the EMR. Education conducted by the Utah Department of Health certified trainer was demonstrated to be effective through statistically significant knowledge and confidence level change. Insight gleaned from members of the healthcare team through surveys, interviews, and focus groups revealed that pregnancy intention screening is valued at all levels of the women's healthcare specialty but concerns about the feasibility of system-wide implementation are prevalent. Thus, implementation of OKQ outside of the women's health specialty area will require multi-disciplinary buy-in of how routine pregnancy intention screening has the potential to have a widespread impact on reducing unintended pregnancy rates while also improving maternal and infant morbidity and mortality. It is likely that training facilitated by provider champions within the women's health specialty will help providers in other speciality areas to buy-in to the importance of this screening. Limitations BARRIERS AND FACILITATORS TO IMPLEMENTING ONE KEY QUESTION® Page 16 This project was conducted in a large University Health System with women's health providers who specialize in meeting the needs of women throughout their lifespan. Thus, the information may not be directly applicable to general practitioners or specialists outside women's health. Also, with the patient population served within this health system not being diverse in terms of race or ethnicity, findings may not be directly applicable to more diverse communities. Due to the short amount of time allotted with the OB/GYN providers, pre-tests were not administered prior to the education session. The education was condensed and was also not conducted by the same individual as the CNM education. Thus, conclusions about the effectiveness of the education provided by the Utah Department of Health cannot be extended beyond the CNM population. Conclusions Implementing OKQ into the BCHC practice would provide the opportunity to provide holistic care informed by the woman's reproductive intentions for nearly 5,000 women each year. However, implementation in the BCHC practice would only provide screening for four percent of women of reproductive age within the University of Utah health system. If adopted by the OB/GYN clinical practice nearly eighteen percent of women would be screened. While it would be hard to argue against providing women with holistic care informed by their pregnancy intentions, implementation system-wide will require considerable buy-in from all levels of the healthcare system. Although most clinicians report discussing pregnancy intentions, without standard methods to conduct and document this work, it is difficult to ascertain how often this discussion is taking place. With time being the largest barrier identified by all levels of the healthcare team, and implementation into the EMR identified as the best tool to facilitate implementation, working with a multi-disciplinary team to ensure EMR integration will allow clinicians to efficiently conduct the screening and provide guidance will be essential to implementation success. Standardization in documentation and billing within the EMR will aid future data collection and analysis to afford the ability to draw conclusions about whether this screening and counseling impacts important measures such as unintended pregnancy rates. Ultimately, all women have the right to be informed about preconception health and their options to reduce the incidence of unintended pregnancy. Therefore, it is imperative that all healthcare providers routinely screen women about their pregnancy intentions and provide reproductive guidance based on BARRIERS AND FACILITATORS TO IMPLEMENTING ONE KEY QUESTION® Page 17 their intention. OKQ presents a promising approach to ensure that all women with reproductive capabilities are screened during all health encounters and warrants additional investigation. Acknowledgements Project Chair: Ana Sanchez-Birkhead Content Experts: Sara Simonsen and Rachael Hemmert Project was completed as a part of a small grant funded by the March of Dimes. Other Acknowledgements: Katie Ward (initial project chair), Rachael Hemmert (research assistant), Clinic managers / key stakeholders, Data pull team, EPIC personnel, CNM and MA interviewees, and education attendees
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