Analyzed the reliability of depression screening and follow-up processes in a primary care setting, focusing on structural workflow failure points rather than clinical outcomes alone.
Context
CMS quality measures require routine depression screening (PHQ-2 followed by PHQ-9 when indicated) and documented follow-up plans. In practice, completion rates and follow-up adherence vary due to workflow complexity rather than clinical disagreement.
The objective of this project was to analyze the screening process as a system and identify where reliability degrades.
System Mapping
The full workflow was decomposed from patient intake through:
- Intake documentation
- PHQ-2 administration
- PHQ-9 escalation logic
- Provider review
- Follow-up documentation
- Referral and care coordination
Each transition point was analyzed for task ownership, dependency, and failure sensitivity.
Hierarchical Task Analysis (HTA)
A formal HTA was constructed to:
- Identify nested task dependencies
- Clarify conditional branching (e.g., PHQ-2 positive → PHQ-9 required)
- Surface hidden coordination steps
- Reveal where omission errors were most likely
The HTA made explicit where screening success depends on cross-role coordination rather than a single actor.
Reliability Risks Identified
Structural risks included:
- Task ambiguity between intake staff and providers
- Conditional escalation steps dependent on manual interpretation
- EHR interface friction
- Documentation lag affecting quality reporting
The key insight was that screening compliance is less a knowledge problem and more a process integrity problem.
Design Implications
Improving outcomes would likely require:
- Standardized task sequencing
- Clear ownership assignment
- Interface simplification
- Reduced reliance on memory-dependent transitions
The analysis reframed depression screening as a workflow reliability issue rather than a purely clinical adherence issue.