Improving Chronic Illness Care: Development of Routine Patient Self-Assessment

1. Improving Chronic Illness Care: Development of Routine Patient Self-Assessment Alexander S. Young, MD, MSHS VA Desert Pacific MIRECCUCLA

2. Overview • Chronic illness • informatics to improve care • CHIACC project (HSR&D / QUERI) • Improving mental health care • challenges • Developing patient self-assessment

3. Chronic Illness • Hypertension, diabetes, asthma, drug abuse, depression, schizophrenia, etc. • Common • 100 million have 1 or more • Not well treated • people in care receive 56% of effective treatments • “Tyranny of the urgent” (Wagner) • brief treatment visits • patients not educated and supported • Little oversight regarding the quality of care

4. Improving Care • Requires coordinated, proactive care • system focused on acute care • Chronic disease care models • collaborative, team-based • support patient self-management • Goals • improve care quality • reduce morbidity and mortality

5. EMR:Transformation of the VA Jha et al, NEJM 2003; Kerr et al Ann Intern Med 2004

7. Challenges in Chronic Illness Care • EMR has limited data • EMR data not well organized • relevant data during the clinical encounter • decision support • Guidelines rarely used • Communication is difficult • among clinical team • with patient

8. How Can IT Help? • Support collection of standard data • Organize data • decision support for clinicians • Facilitate communication • Manage care of populations • support reorganization of care • Support illness self-management

9. CHIACC • Funded by VA HSR&D and QUERI • Clarify informatics approaches that help improve chronic illness care • Develop and evaluate software • in mental health • high in usability • interfaces with VA EMR

10. Creating HealtheVet Informatics Applications for Collaborative Care (CHIACC):The Team Los Angeles, CaliforniaAlexander S. Young, MD, MSHS (Co-PI)Amy N. Cohen, PhDJim Mintz, PhDJennifer Pope, BSRebecca Shoai, MPH, MSW Seattle, Washington Edmund Chaney, PhD (Co-PI)Laura Bonner, PhD Youlim Choi Laura RabuckCarol Simons Oregon Health & Science UniversityDavid Dorr, MD, MS Ann Arbor, MichiganEve Kerr, MD, MPH Steering CommitteeNick Dewan, MDJohn Fortney, PhDMary Goldstein, MDRuth Perrin, MASusan Vivell, PhD PAS SystemMatthew Chinman, PhDJoe Hassell, MAJennifer Magnabosco, PhDJim Mintz, PhD

11. CHIACC Methods Phase 1a: Literature review Phase 1b: Achieve expert consensus on informatics support requirements for chronic illness care Phase 2: Design and test software modules Phase 3: Develop software and conduct usability evaluation

12. CHIACC Results • To be discussed

13. Serious, Persistent Mental Illness • Common & disabling • prevalence of 3% - 5% • Effective treatments exist • medication, psychotherapies, rehabilitation • Low use of appropriate care • chronic depression: only 1/3 get medication or psychotherapy • schizophrenia: many do not receive vocational rehabilitation, family services, clozapine, or side-effect management interventions

14. Improving Care Nationally • President’s New Freedom Commission • VHA Mental Health Strategic Plan • How to implement effective treatments? • Major challenge: lack of routine, valid outcomes data • no important lab tests or vital signs • chart notes lack reliable clinical data • not possible to know who needs each treatment & whether they improve • very different problem from diabetes, hyperlipidemia, HTN, etc.

15. Routine Outcomes Data to Inform Quality Improvement • Potential solutions • assessment by physicians or nurses • assessment by trained staff • self-assessment by patients • Research questions • 1) is self-assessment accurate • 2) is routine self-assessment feasible and useful at typical mental health clinics

16. Routine Outcomes Data:Self-Assessment by Patients • Patient Assessment System (PAS) • audio computer-assisted self-interviewing (ACASI) • touch-screen computer “kiosk” • web browser • www.npistat.com/pasdemo/ or 10.180.1.76/pasdemo/ (username and password are “guest”)

17. Psychometric Study: Methods • Convenience sample • patients with schizophrenia or bipolar (n=90) • Clinical research survey • BASIS-R, side-effects, QOL • face-to-face vs. ACASI • 20 minutes apart separated by distracter task • order was counter-balanced • Usability survey • comprehension, speed of completion, preferences

18. Results • Internal consistency: same between modes • Concurrent validity • high test-retest reliability between modes: r = .81 - .99 • no bias across mode (adjusted for order) • Usability • no difference in speed: 15 minutes • perfectly answered questions about how to use it: 97% • easier to take? 86% ACASI • like it more? 87% ACASI • if required to take every month? 84% ACASI • more private? 60% ACASI

20. Conclusions • Routine computerized self-assessment in chronic mental illness • reliable & valid • easy to implement • well received by patients • clinician acceptance varies substantially • Improve care • needs to be integrated with improved service delivery • Use with other cognitive disorders?

21. Future Directions • Clinical research • community-based practice research networks • Services research • support quality improvement in mental health • VA healthcare • integrate with VA data systems / Mental Health Assistant • My HealtheVet

23. References • Bodenheimer T, Wagner EH, Grumbach K: Improving primary care for patients with chronic illness. JAMA. 2002; 288: 1775-9. • Chinman M, Young AS, Schell T, Hassell J, Mintz J: Computer-assisted self-assessment in persons with severe mental illness. Journal of Clinical Psychiatry. 2004; 65: 1343-1351. • Cradock J, Young AS, Sullivan G: The accuracy of medical record documentation in schizophrenia. Journal of Behavioral Health Services & Research. 2001; 28: 456-65 • Dorr D, Bonner LM, Cohen AN, Shoai RS, Perrin R, Chaney E, Young AS: Informatics systems to promote improved care for chronic illness: A literature review. under review. • Institute of Medicine: Key Capabilities of an Electronic Health Record System. National Academies Press, Washington, DC: National Academies Press; 2003. • Young AS, Sullivan G, Burnam MA, Brook RH: Measuring the quality of outpatient treatment for schizophrenia. Archives of General Psychiatry. 1998; 55: 611-7

24. References • Young AS, Mintz J, Cohen AN: Clinical computing: using information systems to improve care for persons with schizophrenia. Psychiatric Services 2004; 55:253-5 • Young AS, Mintz J, Cohen AN, Chinman MJ: A network-based system to improve care for schizophrenia: the medical informatics network tool (MINT). J Am Med Inform Assoc. 2004; 11: 358-67. • Young AS, Mintz J, Chinman M: The Patient Assessment System (PAS). Demonstration available at www.npistat.com/pasdemo (username and password are “guest”). • Young AS, Magnabosco JL: Services for adults with mental illness. In: Levin BL, Petrila J, Hennessy KD, eds. Mental Health Services: A Public Health Perspective. New York NY: Oxford University Press; 2004:177-208. • Young AS, Cohen AN, Mintz J: A vignette in the chapter on information systems. In: The Institute of Medicine, eds. Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series. Washington DC: National Academies Press; 2005:241-242.

25. Acknowledgements • VA HSR&D and QUERI (RCD 00-033, CPI 99-383, MHS 03-218) • VA Desert Pacific Mental Illness Research, Education and Clinical Program (MIRECC) • NIMH UCLA-RAND Center for Research on Quality in Managed Care • For further information • Alexander S. Young, MD MSHS • MIRECC, West Los Angeles VA Healthcare Center,11301 Wilshire Blvd. (210A), Los Angeles CA 90073