Use of a Registry for Chronic Disease Management in a Small County Behavioral Health Setting

1. Use of a Registry for Chronic Disease Management in a Small County Behavioral Health Setting Karen Stockton, Ph.D., M.S.W., B.S.N. Health Services / Behavioral Health Director, Modoc County

2. Platform Selection: The Small County Challenge • Be able to accomplish with minimal technological support • Be able to embed as a normal part of service delivery • Be simple enough that MH Specialists and Peer providers can use • Be able to produce and interpret basic reports without statistical expertise • Note: as a very small county, we were exempt from PEI evaluation

3. Background • We were looking for an inexpensive system that was appropriate for small county data management to measure outcomes across all programs and funding requirements. • Desired an application that had promise for real-time quality improvement at all system levels, was appropriate for integrated health care, and that would also have capacity to submit data to oversight entities. • We decided early on to set the security level to comply with HIPPA & 42CFR – and manage access by release of information.

4. Our journey in search of an alternative to pencil and paper tracking • Pencil & Paper • Spreadsheets • Stand alone with limited use for general population or interface with other programs • EHR • The primary use of an electronic health record is mostly to process billing and supporting documentation. • Much of the data is not in searchable fields. • Chronic Disease Management Registry

5. Adaptability • A registry is designed to be more adaptable to collect needed information. • Data available at all levels of program (client, groups of the population) • Makes job easier – no paper chart • Makes it possible to do things that we couldn’t do before • Plan with our beneficiaries their treatment based on their progress reports • Staff use individual data for planning and intervention while in session

6. Testing chronic disease management registries (PECSYS & eCiMH CC Tracker) • Registry is a tool to help you keep track of people and manage their health.

7. Interfaces Data Input • Direct data entry via web access • Data entry notices/reminders • Mobile system entry with web access • Data import • From providers’ systems under testing through EHR interface Data Output users • Data exports • Canned reports • Custom reports Role based interfaces (front desk, clinician, QA, billing, IT, management) • System administration • Users support

10. Content & Outcomes • Structure and Process Information • Can collect any measurable information that is predetermined and assigned a field • Outcomes Information • Client Outcomes • Core measures (across programs) • Custom measures (specific to a program) • Program Outcomes • Milestones • G&O – If assigned a numeric value

13. Annotated Time Series

14. Santa Maria County Mental Health

15. Data Utilization of the Registry • Use data proactively manage health and wellness for a chronic condition • Collect and use data for integration of whole health and shared care plans • Collect and analyze data that is useful for quality improvement • Demonstrate individual progress and program outcomes • Guide delivery of, and monitor adherence to, best practices and protocols

16. Provide a mechanism to share key information across the integrated team through VPN or HIE – ACA data exchange requirements • With appropriate releases of information, through VPN access, integrated team members can bi-directionally exchange information “real time”. • Client level data in aggregate is very useful for demonstration of program/department and collaborative outcomes • Fixed data elements in “searchable fields” have significant potential for TIMELY outcome measurement, evaluation and/or research at all system levels while remaining HIPPA/and 42CFR compliant.