Facilitating Implementation of a Depression Care Management Intervention Using Web-Based Decision Support NetDSS Facilitating Implementation of a Depression.

NetDSS

Facilitating Implementation of aFacilitating Implementation of aDepression Care Management Intervention Depression Care Management Intervention

Using Web-Based Decision SupportUsing Web-Based Decision Support

John Fortney, PhDJohn Fortney, PhD

June 17, 2008 June 17, 2008

South Central MIRECCSouth Central MIRECCHSR&D Center for Mental Health and Outcomes ResearchHSR&D Center for Mental Health and Outcomes Research

HSR&D Mental Health QUERIHSR&D Mental Health QUERI

Central Arkansas Veterans Healthcare SystemCentral Arkansas Veterans Healthcare System

Funding SourcesFunding Sources

VA IIR 00-078-3VA IIR 00-078-3 VA IMV 04-360 VA IMV 04-360 VA MNT 05-152 VA MNT 05-152 NIMH R01 MH076908-01NIMH R01 MH076908-01

Clinical BackgroundClinical Background

75% of patients treated for depression 75% of patients treated for depression receive care in primary care settingsreceive care in primary care settings

20-50% of primary care patients stop taking 20-50% of primary care patients stop taking medications in the first month of treatmentmedications in the first month of treatment

30-50% of primary care patients don’t 30-50% of primary care patients don’t respond to the initial medicationrespond to the initial medication

15-30% of primary care patients treated for 15-30% of primary care patients treated for depression receive guideline concordant depression receive guideline concordant care.care.

Components of Collaborative CareComponents of Collaborative Care

Use of informatics to track critical processesUse of informatics to track critical processes

Use of clinical practice guidelinesUse of clinical practice guidelines

Stepped care modelStepped care model

Ready access to mental health specialistsReady access to mental health specialists

Delegation of key provider functions to non-Delegation of key provider functions to non-physician members of a practice teamphysician members of a practice team

Care ManagementCare Management

Depression Care ManagementDepression Care Management

Education and activationEducation and activation Barrier assessment and resolutionBarrier assessment and resolution Comorbidity assessmentComorbidity assessment Depression symptom monitoringDepression symptom monitoring Suicide risk assessmentSuicide risk assessment Medication adherence monitoringMedication adherence monitoring Side-effects monitoringSide-effects monitoring Self Management goal setting and monitoringSelf Management goal setting and monitoring

Telemedicine-Based Collaborative Telemedicine-Based Collaborative Care for CBOCsCare for CBOCs

Offsite depression care team Offsite depression care team Nurse care manager Nurse care manager PharmacistPharmacist PsychiatristPsychiatrist

TelephonesTelephones Care manager encounters with patients at home Care manager encounters with patients at home

Interactive VideoInteractive Video Psychiatric evaluations with patients at CBOCPsychiatric evaluations with patients at CBOC

Electronic Medical Records (CPRS)Electronic Medical Records (CPRS) Communication among on-site PCPs and offsite depression care Communication among on-site PCPs and offsite depression care

teamteam

Effectiveness of TEAM InterventionEffectiveness of TEAM Intervention

TEAM StudyTEAM Study1,21,2 – Randomized effectiveness – Randomized effectiveness trial of telemedicine-based collaborative care in trial of telemedicine-based collaborative care in rural CBOCsrural CBOCs

Increased medication adherenceIncreased medication adherence Increased rates of response and remissionIncreased rates of response and remission Increased health statusIncreased health status Increased patient satisfactionIncreased patient satisfaction

1.1. Fortney JCFortney JC, , Pyne JM, Edlund MJ, Robinson DE, Mittal D, Henderson KL. Design and Pyne JM, Edlund MJ, Robinson DE, Mittal D, Henderson KL. Design and Implementation of the Telemedicine-Enhanced Antidepressant Management Study. Implementation of the Telemedicine-Enhanced Antidepressant Management Study. General Hospital Psychiatry, 28(1): 18-26, 2006General Hospital Psychiatry, 28(1): 18-26, 2006

2.2. Fortney JCFortney JC, , Pyne JM, Edlund MJ, Robinson DE, Mittal D, Henderson KL. A Randomized Pyne JM, Edlund MJ, Robinson DE, Mittal D, Henderson KL. A Randomized Trial of Telemedicine-Based Collaborative Care for Depression, Trial of Telemedicine-Based Collaborative Care for Depression, Journal of General Journal of General Internal Medicine,Internal Medicine, in press. in press.

Medication AdherenceMedication Adherence Casemix-Adjusted Results Casemix-Adjusted Results

50

55

60

65

70

75

80

85

90

Pro

bab

ilit

y

S ix M o n th s T w elve M o n th s

U su al C are

In terven tio n

OR=2.1p=0.04

OR=2.7p<0.01

Response Response Casemix-Adjusted Results Casemix-Adjusted Results

0

5

10

15

20

25

30

35

40

45

50

Pro

bab

ilit

y

S ix M o n th s T w elve M o n th s

U su al C are

In terven tio n

OR=1.9p=0.02

OR=1.4p=0.18

RemissionRemissionCase-mix Adjusted ResultsCase-mix Adjusted Results

0

5

10

15

20

25

30

35

40

45

50

Pro

bab

ilit

y

S ix M o n th s T w elve M o n th s

U su al C are

In terven tio n

OR=1.8p=0.14

OR=2.4p=0.02

Mental Health Component (MCS) Mental Health Component (MCS) Casemix-Adjusted ResultsCasemix-Adjusted Results

0

5

10

15

Ch

ang

e in

MC

S

S ix M o n th s T w elve M o n th s

U su al C are

In teven tio n

P=0.07

P<0.01

SatisfactionSatisfaction Casemix-Adjusted Results Casemix-Adjusted Results

30

40

50

60

70

80

90

100

Pro

bab

ilit

y

S ix M o n th s T w elve M o n th s

U su al C are

In terven tio n

OR=1.8p=0.01

OR=1.7p=0.03

Implementation ResearchImplementation Research Partners In Care studyPartners In Care study

Fidelity to the care manger protocol was lower than Fidelity to the care manger protocol was lower than anticipated anticipated

Computerized tracking system was recommended Computerized tracking system was recommended as a resultas a result11. .

RIPPLE Study RIPPLE Study Implement telemedicine-based collaborative care in Implement telemedicine-based collaborative care in

contract CBOCs.contract CBOCs. Decision Support System was needed to maintain Decision Support System was needed to maintain

fidelityfidelity to the evidence base during implementation? to the evidence base during implementation?

1.1. Rubenstein LV, Jackson-Triche M, Unutzer J, Miranda J, Minnium K, Pearson M, Wells K. Rubenstein LV, Jackson-Triche M, Unutzer J, Miranda J, Minnium K, Pearson M, Wells K. Evidence-Based Care for Depression in Managed Primary Care Practices, Health Affairs, Evidence-Based Care for Depression in Managed Primary Care Practices, Health Affairs, 18(5): 89-105, 1999.18(5): 89-105, 1999.

Design and Development of Design and Development of NetDSSNetDSS

Cross-functional Design Team Cross-functional Design Team

Bill Raney, RN – Depression Care ManagerBill Raney, RN – Depression Care Manager Amanda Davis MA – Technical WriterAmanda Davis MA – Technical Writer Chris Steven – Web programmerChris Steven – Web programmer Silas Williams – Web programmerSilas Williams – Web programmer Richard Hedrick – Systems AnalystRichard Hedrick – Systems Analyst Jeff Pyne, MD – PsychiatristJeff Pyne, MD – Psychiatrist John Fortney, PhD – TranslatorJohn Fortney, PhD – Translator

ScopeScope

Users – Care ManagersUsers – Care Managers Patients – PC patients with depressionPatients – PC patients with depression Timing – Between PC visitsTiming – Between PC visits Purpose Purpose

Panel managementPanel management Trial managementTrial management Structured assessmentStructured assessment Decision supportDecision support Workload and Outcomes ReportsWorkload and Outcomes Reports

AttributesAttributes NetDCMS was designed to have most of the required features of a NetDCMS was designed to have most of the required features of a

clinical information system as outlined in a recent article by clinical information system as outlined in a recent article by Kilbourne and colleagues (2006) including:Kilbourne and colleagues (2006) including:

Short training time, with uncluttered screens that are easy to navigateShort training time, with uncluttered screens that are easy to navigate Web-based Web-based Use of drop menus and logic checksUse of drop menus and logic checks Compliant with HIPAA standards and conforms to standards to internet Compliant with HIPAA standards and conforms to standards to internet

security/encryptionsecurity/encryption Use of clinic remindersUse of clinic reminders Capability of creating individual care plans with self-management Capability of creating individual care plans with self-management

information and disease severity ratinginformation and disease severity rating Capacity to print out summary data on quality and other patient Capacity to print out summary data on quality and other patient

outcomesoutcomes Linked with, but not a substitute for electronic medical recordsLinked with, but not a substitute for electronic medical records Supports multiple chronic illnessesSupports multiple chronic illnesses

1.1. Kilbourne AM, McGinnis GF, Belnap BH, Klinkman M, Thomas M. The role of clinical Kilbourne AM, McGinnis GF, Belnap BH, Klinkman M, Thomas M. The role of clinical information technology in depression care management. information technology in depression care management. Adm Policy Ment HealthAdm Policy Ment Health. 2006 . 2006 Jan;33(1):54-64. Jan;33(1):54-64.

FeaturesFeatures NetDSS has the following functional capabilities: NetDSS has the following functional capabilities:

patient registry and panel managementpatient registry and panel management trial and phase managementtrial and phase management encounter schedulerencounter scheduler decision supportdecision support progress note generatorprogress note generator workload report generatorworkload report generator

NetDSS guides the care manager through a NetDSS guides the care manager through a self-documentingself-documenting and and evidence-basedevidence-based patient encounter using scripts and self-scoring patient encounter using scripts and self-scoring instruments which support: instruments which support:

patient education and activationpatient education and activation barrier assessmentbarrier assessment comorbidity assessmentcomorbidity assessment depression severity monitoringdepression severity monitoring suicide risk assessmentsuicide risk assessment adherence monitoringadherence monitoring side-effect monitoring side-effect monitoring self-management activitiesself-management activities

Story BoardStory Board

Database

Care manager [ clinic [ provider [ patient ] ] ]

Trial types [ phases [ success/failure ] ]

Instrument scoring

Outcomes tracking

Automated Treatment Recommendations

Registry

EncounterScheduler

Assessments

Workload Report

Progress Notes

Decision Support

Assembling the Assembling the ComponentsComponents

Story Board

Database Structure

User Interface

Evidence-Based Protocols

Trial Management

Instruments and Scripts

Panel Management

Decision Support

DecisionsDecisions

CPRS vs. stand-alone applicationCPRS vs. stand-alone application Target VA vs. private sector vs. bothTarget VA vs. private sector vs. both Web-based vs. CD-ROMWeb-based vs. CD-ROM Flexible vs. structuredFlexible vs. structured User friendly vs. efficientUser friendly vs. efficient

Development ProcessDevelopment Process

Rapid prototype-test-prototype product development Rapid prototype-test-prototype product development cyclescycles

Monthly planning meetingsMonthly planning meetings ProgrammingProgramming User testingUser testing Revisions & additionsRevisions & additions

Continuous beta test version (2 years)Continuous beta test version (2 years)

Users Guide & Training ManualUsers Guide & Training Manual

Version 1.x with biannual updates (1.5 years)Version 1.x with biannual updates (1.5 years)

Current UsersCurrent Users VA RIPPLE Study (Contract CBOCs)VA RIPPLE Study (Contract CBOCs)

Little Rock, AR Little Rock, AR Loma Linda, CA Loma Linda, CA Los Angeles, CALos Angeles, CA

VA HiTIDES Study (VA Medical Centers)VA HiTIDES Study (VA Medical Centers) Little Rock, ARLittle Rock, AR Houston, TXHouston, TX Atlanta, GA Atlanta, GA

NIMH OUTREACH Study (Federally Qualified Health Centers)NIMH OUTREACH Study (Federally Qualified Health Centers) Little Rock, ARLittle Rock, AR Pine Bluff, ARPine Bluff, AR West Memphis, ARWest Memphis, AR Lepanto, ARLepanto, AR Corning, ARCorning, AR Pochahontas, ARPochahontas, AR Huntsville, ARHuntsville, AR

PC/MH Integration InitiativePC/MH Integration Initiative Little Rock, ARLittle Rock, AR New Orleans, LANew Orleans, LA

Web-SitesWeb-Sites

Non-VA Version URLNon-VA Version URL https://www.netdss.net/https://www.netdss.net/

VA Version URLVA Version URL Send request from VA.gov email to:Send request from VA.gov email to:

• [email protected]@va.gov • [email protected]@VA.gov

NetDSS DemonstrationNetDSS Demonstration