MHA Overview VIREC Cyberseminar

1. MHA OverviewVIREC Cyberseminar Kathleen Lysell, PsyD Rick Owen, MD November 20, 2007

2. Session Objectives • Be familiar with the VHA Mental Health Assistant software, including its use and applications in clinical care; • Understand how the software could be used in a research setting; • Understand the process for creation of national database of MHA assessment data; and • Know about how the implementation of the software was evaluated

3. Mental Health Assistant Software

4. Mental Health Assistant • Graphical User Interface (GUI) for the Mental Health testing package. • Originally released 2002 • Provides secure computer environment for patient administered testing • Only VistA application currently available that stores survey/self report information as data • 2,800,000 assessments using MHA instruments completed in FY07

5. Instruments Currently Available in MHA

6. MHA3 New Features—Patch YS*5.01*85 • MHA files completely restructured in VistA • Launch from CPRS Tools Menu • Pass progress note to CPRS • New Instruments for MH Screening, nursing, TBI • With clinical reminders patch 6, all MHA instruments will work with reminders • Reminders will be able to use MH scales and individual responses in finding logic

7. Current System MH Test Files

8. MH Files New with Patch YS*5.01*85

9. What does file structure mean? • Old structure, results only stored as response string TTFT, report recalculated on the fly every time test accessed • Very difficult to research test results on long tests • All tests had to be coded into system using mumps

10. New File Structure • Series of connected files that store entire test administration data • Can evaluate scales, questions, raw or transformed scores rather than just response strings • Greatly facilitates addition of new test content—create instrument using Delphi tool that translates it to mumps file structure • HL7 messaging used to create national testing database

11. New Instruments Added in MHA3 • BOMC (Blessed Orientation Memory Concentration) Test • Braden Skin Risk Assessment • Morse Falls Risk Scale • PHQ-2 • PC-PTSD • TBI 2nd Level Evaluation

12. Modified Instruments in MHA3 • AUD-C: Invoke Skip Logic; add option “Never” as response to Item 1 and “0” as response to Item 2 • PHQ-9: Add 10th question regarding impact of symptoms on overall functioning

16. PHQ-9 Test Form in MHA3

20. MHA Research Example—AUDIT-C • AUDIT-C response strings from alcohol use screens were extracted from VistA at a VA facility (n=65,484 AUDC response strings) for a 2 year period. • 90 combinations were identified for all AUDIT-C scores. 11 response strings were identified that equal a score of 4 (see chart). • The most common drinking pattern representing a score of 4 was 400 (n= 11387, 17% of all combinations) - drinking 1-2 drinks daily, but never drinking > 6 drinks per occasion (binge drinking). The “400” response string accounted for 83% of all scores equaling 4. • There were 1249 (1.9% of all combinations) occurrences where the score was 4 and the response string indicated binge drinking, as represented by any response string with a 3rd digit of 1 or more (e.g. 211,301,112). This pattern accounted for 9% of all scores equaling 4.

21. AUD-C Response String Frequency

22. Item checked equals 2 points Item checked equals 1 point Item checked equals 1 point AUDIT-C Response Samples

23. Enhancements in Clinical Reminders • Clinical Reminders updated it’s code with patch PXRM*2.0*6, to work with new MH files • Can work with MH scale within an instrument, or specific item within an instrument as reminder finding

24. Reminders Using MH Item Response • FINDING ITEM: AUDC// • MH SCALE: 276//default of scales associated with the instrument • CONDITION: I V("R",1)="Four or more times a week“ if the value of response to Item 1 is “four or more times a week”

25. AUD-C Response String in Reminder Logic • Condition: I V("R",1)=“Four or more times a week” • Condition: I V("R",2)="3 or 4" • Condition: I V("R",3)="Never" • Function String: FI(2)&FI(3)&FI(4) Expanded Function String: FI(AUDC,R,1)&FI(AUDC,R,2)&FI(AUDC,R,3) Found Text: Patient who might drink less than the safe limits.

27. Using Reminders with MH Instruments • Identify population, desired frequency of measurement • MH Performance Measures, FY08 • PHQ-9, AUD-C, PC-PTSD • PC MH Integration Assessment • PHQ-9, BAI, PCL, AUD-C

28. Testing Database • MH testing data stored in local VistA files • MHA3 enhancements also create national testing database • Test administrations transmitted using HL7 messaging • Physically located in Pittsburgh, MH Informatics section • Only includes test administration data, only data generated after MHA3 patch is installed in local system • Establishing protocols for data usage with Austin Corporate Data Warehouse

29. Project Review, Lessons Learned

30. Business Case • MHA is a national software package; the mental health package was one of the early clinical packages in VistA • Significant cost savings/benefit identified in automating psychological testing process • Improved clinical processes demonstrated

31. Expanding Presence • Software historically limited to MH usage, but functionality valuable in other clinical settings • Identified as tool that will store self report information as data rather than text • Useful in decision support • Easy to add content in environment where new development is difficult to fund • Interact with clinical areas that have specific assessment by self report needs to broaden investment • Integrate with CPRS • Provide tools requested by program offices

32. Approval Process • Submit Project Requests to HISEB • HISEB prioritizes all requests in portfolio • IDMC reviews priorities of 5 HISEB’s • Funding based on budget from Congress • Executive priorities funded off the top • Multi-year projects that are approved receive funding priority in subsequent years

33. Issues • Sites do not utilize full capacity of package • Perception that it is only for psychological testing • Adequate resources to have computers and space to use for patient administration • Extended period of significant restriction of development resources • Uncertainty around VA software development strategies

34. Next Steps

35. Clinical Content • Immediate goal • Suicide prevention, TBI follow-up evaluation—high visibility, high priority items • Behavioral health—pain • Mental health—recovery oriented assessment tools • Geriatrics, HBPC assessment tools

36. Authoring Tool • Use to build local instruments • Delphi application—no programming experience necessary • Builds questionnaires with scoring rules and reports templates

39. VUID • Veteran Unique Identifier • Link to Enterprise Reference Terminology • Using SNOMED to code each item in MH tests • Provide Standardized coding/terminology associated with elements of assessments

40. References • Graham, A., et al. (2007). Effect of using different modes to administer the AUDIT-C on identification of hazardous drinking and acquiescence to trial participation among injured patients. Alcohol and Alcoholism, 42, 423-429 • Bush, K., et al. (1998). The AUDIT Alcohol Consumption Questions (AUDIT-C) An Effective Brief Screening Test for Problem Drinking. Archives of Internal Medicine, 158, 1789-1795. • Achtmeyer, C et al (2007). Using Mental Health Assistant AUDIT-C Data to Describe Patterns of Alcohol Use.  VeHU Conference, Orlando, FL. http://vaww.vehu.med.va.gov/vehu/vehu2007/ppt/9903_LL.ppt