Computers and information technology: implications for the 21st century.

The rapidly changing world of computer and information technology will have dramatic changes for adolescent medicine clinicians in the 21st century. This article reviews some of this evolving technology, including the electronic medical record, the Internet, and telemedicine as well as various advances in health screening, assessment, and education. The importance of integrating this technology into a total information system is stressed. The article concludes with a day in the life of an adolescent medicine clinician in the new century.

Computer-assisted health counselor visits: a low-cost model for comprehensive adolescent preventive services.

OBJECTIVE: To evaluate a low-cost strategy for providing preventive health services to adolescents using computerized health assessments with individualized educational videos, trained health counselors, and nurses. DESIGN: Feasibility study, cost analysis, and comparative evaluation of health problems identified, guidance delivered, and patient satisfaction. SETTING: Eleven sessions at nontraditional sites including schools, universities, shopping malls, and after-hours clinics on Oahu, Hawaii. PARTICIPANTS AND INTERVENTION: Adolescents (N=258, mean age 17 years) completed confidential computerized health assessments, received individualized feedback, and viewed automatically selected educational videos on a laptop computer. The computer additionally printed a prioritized problems list for the graduate student-level health counselor to review with the adolescent. The counselor subsequently reviewed each encounter with a nurse-educator who performed further counseling and physical examinations when indicated. RESULTS: Visit length averaged 44 minutes. Subjects spent an average of 21 minutes completing the automated health assessment and viewing interactive multimedia and 15 minutes with the health counselor. One third of subjects required further evaluation and counseling by the nurse (average, 8 minutes). A team of 2 counselors and 1 nurse provided comprehensive screening, health counseling, and physical examinations to 1 patient every 10 minutes at a salary cost of $7.46 per visit. This model identified risk behaviors at levels consistent with local behavioral data, and addressed and documented them significantly more often than do physicians in traditional settings. Subjects (71%) preferred the computer-assisted visits to standard office visits, and 92% felt the amount of time spent was acceptable. CONCLUSIONS: Computer-assisted delivery of adolescent preventive services using nonphysician health counselors is a feasible, economical, and acceptable alternative to traditional clinical practice for screening young people for health-compromising behaviors and providing individualized health education and routine physical examinations. This model would likely increase adolescents' access to needed preventive services at a very modest cost.

Computerized health assessment and education for adolescent HIV and STD prevention in health care settings and schools.

This report summarizes a number of computer applications from a decade of experience with computerized adolescent health assessments and automated health education in a large health maintenance organization, military adolescent clinics, detention facilities, health fairs, and public schools. Feedback from over 5,000 adolescents is given for patient responses to and acceptance of computerized health assessments and preferences for automated health education modalities, including multimedia. Implications of the computerized approach to assessment of adolescent health risk behaviors and the provision of automated health education and HIV/STD prevention are considered in terms of efficiency, reliability, and access to health screening and educational services.

HMO innovations. Video-enhanced medical advice; senior zoo walkers; Group Health Resource Line; enhancing health education programs through desktop publishing; home health beat; innovative school health partnership.

The editors of HMO PRACTICE asked clinicians and health educators in HMOs across the country to submit reports on their unique, successful patient education programs. The following HMO Innovations testify to the wide range of new technologies, enterprising partnerships, and creative ideas that are shaping health education in HMOs today.

Computer-assisted detection and intervention in adolescent high-risk health behaviors.

Because adolescents avoid bringing sensitive issues, such as substance abuse, suicide, and sexual activity, to pediatricians, and may fail to realize that they need health education or services, a computer program was designed to facilitate reporting of high-risk psychosocial and health behaviors and to provide specific health advice and referral for timely professional intervention. Computer printouts done anonymously by a random sample of 265 adolescents after a physical examination were compared with those of a matched group of 294 who were predirected to share the printout with the clinician at their examinations. The former elicited more positive responses to sensitive health problems, but both computer groups responded significantly more often about most high-risk issues than a matched written questionnaire group of 251. Almost all adolescents said that they reported true information to the computer and read all the information it printed. Experience with 3327 teenagers demonstrated that 89% preferred the computer over a questionnaire or personal interview, but nearly all were willing to share the printout with the pediatrician, which should facilitate clinical evaluation. The nonjudgmental computer can identify problem areas and deliver automated medical advice and referral. Automated health assessment and education may become a useful adjunct for addressing adolescent health issues.

Adolescent pregnancy prevention by health education computer games: computer-assisted instruction of knowledge and attitudes.

Adolescents enjoy animated-action computer games that capture and hold attention. In this study, the use of computer-assisted instruction in improving knowledge and attitudes in favor of decreased teenage pregnancy is evaluated. Computer-assisted health education is an interactive process and simulates reality. Teenagers explore alternatives and outcomes, and experience consequences of behavioral choices. Two games were designed to promote understanding of the impact and cost of sexual behaviors and parenthood, as well as provide sexual survival skills. Educational evaluation in high schools showed improvements in knowledge and attitudes in these sensitive areas. Test instruments based on the content of each game were developed to assess the impact of the two interventions. Half of the 718 teenagers used the educational programs, and half served as matched control subjects who did not use computer games. Players rated the games highly and evaluated them positively. Measures of 19 factual and psychologic factors associated with pregnancy and parenting were separately made for control and experimental groups. Teenagers who played the games gained knowledge and positive attitude changes to a significantly greater extent than did the comparison group. "The Baby Game!" users increased their knowledge of costs of birth and of costs in money and time of child rearing. "Romance!" users would seek more professional help, had a better understanding of risk of pregnancy, learned more effective means of contraception, and had greater acceptance of oral contraceptives. Teachers and teenagers found the computer games acceptable and fun, and the games reduced counseling time in physician's offices. Computer-assisted instruction is a useful means of providing health education and a promising intervention for adolescent pregnancy.

Maltreatment of adolescents: the relationship to a predisposition toward violent behavior and delinquency.

This discussion reviews the literature concerning the association between the maltreatment, abuse and exploitation of adolescents and the predisposition to violent and other offending behavior. We review the importance and family dynamics of abuse which bear a relationship to antisocial behavior. The distinction is made between child abuse and adolescent abuse, and controversies regarding the sequelae of various maltreatments are discussed. Recent work in sexual abuse and its relationship to male sexual offenders and male prostitutes is detailed. Adolescents who commit various offenses or are in contact with juvenile justice system may be or have been the victims of various forms of maltreatment and exploitation. Helping professionals caring for these youths should have an understanding of these factors and the underlying dynamics.

Adolescent sexual offense behavior: the role of the physician.

This article explores the more common adolescent sexual behavior problems that have legal ramifications, and the role of the physician in approaching such problems. Various presenting sexual offense behaviors are described, as well as the implications for the patient as offender, and finally the parental and physician attitudes necessary to facilitate successful treatment outcomes. Intervention approaches are discussed, and two cases are presented from a group of 83 adolescent male sexual offenders referred to our Juvenile Sexual Offender Project. The discussion and cases illustrate abnormal sexual behaviors which may come to the attention of physicians and other health care professionals.

Chlamydial pelvic inflammatory disease in adolescents.

Two cases of chlamydial pelvic inflammatory disease (PID) are presented. Each was clinically assessed and followed by laboratory methods now available to practitioners. These patients presented with vaginal discharge and chronic abdominal pain. They initially had positive chlamydia cultures which became negative after treatment with tetracycline. Their chlamydia titers increased throughout the course of their disease and treatment. Patient two is a case of the Fitz-Hugh-Curtis syndrome due to chlamydia. The importance of this disease in adolescents and the potential sequelae and complications of chlamydial PID are discussed.