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

NetDSS Facilitating Implementation of a Depression Care Management Intervention Using Web-Based Decision Support. John Fortney, PhD June 17, 2008 South Central MIRECC HSR&D Center for Mental Health and Outcomes Research HSR&D Mental Health QUERI Central Arkansas Veterans Healthcare System.

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

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  1. NetDSSFacilitating Implementation of aDepression Care Management Intervention Using Web-Based Decision Support John Fortney, PhD June 17, 2008 South Central MIRECC HSR&D Center for Mental Health and Outcomes Research HSR&D Mental Health QUERI Central Arkansas Veterans Healthcare System

  2. Funding Sources • VA IIR 00-078-3 • VA IMV 04-360 • VA MNT 05-152 • NIMH R01 MH076908-01

  3. Clinical Background • 75% of patients treated for depression receive care in primary care settings • 20-50% of primary care patients stop taking medications in the first month of treatment • 30-50% of primary care patients don’t respond to the initial medication • 15-30% of primary care patients treated for depression receive guideline concordant care.

  4. Components of Collaborative Care • Use of informatics to track critical processes • Use of clinical practice guidelines • Stepped care model • Ready access to mental health specialists • Delegation of key provider functions to non-physician members of a practice team • Care Management

  5. Depression Care Management • Education and activation • Barrier assessment and resolution • Comorbidity assessment • Depression symptom monitoring • Suicide risk assessment • Medication adherence monitoring • Side-effects monitoring • Self Management goal setting and monitoring

  6. Telemedicine-Based Collaborative Care for CBOCs • Offsite depression care team • Nurse care manager • Pharmacist • Psychiatrist • Telephones • Care manager encounters with patients at home • Interactive Video • Psychiatric evaluations with patients at CBOC • Electronic Medical Records (CPRS) • Communication among on-site PCPs and offsite depression care team

  7. Effectiveness of TEAM Intervention • TEAM Study1,2 – Randomized effectiveness trial of telemedicine-based collaborative care in rural CBOCs • Increased medication adherence • Increased rates of response and remission • Increased health status • Increased patient satisfaction • Fortney JC, Pyne JM, Edlund MJ, Robinson DE, Mittal D, Henderson KL. Design and Implementation of the Telemedicine-Enhanced Antidepressant Management Study. General Hospital Psychiatry, 28(1): 18-26, 2006 • Fortney JC, Pyne JM, Edlund MJ, Robinson DE, Mittal D, Henderson KL. A Randomized Trial of Telemedicine-Based Collaborative Care for Depression, Journal of General Internal Medicine, in press.

  8. Medication Adherence Casemix-Adjusted Results OR=2.1p=0.04 OR=2.7p<0.01

  9. Response Casemix-Adjusted Results OR=1.4p=0.18 OR=1.9p=0.02

  10. RemissionCase-mix Adjusted Results OR=2.4p=0.02 OR=1.8p=0.14

  11. Mental Health Component (MCS) Casemix-Adjusted Results P<0.01 P=0.07

  12. Satisfaction Casemix-Adjusted Results OR=1.7p=0.03 OR=1.8p=0.01

  13. Implementation Research • Partners In Care study • Fidelity to the care manger protocol was lower than anticipated • Computerized tracking system was recommended as a result1. • RIPPLE Study • Implement telemedicine-based collaborative care in contract CBOCs. • Decision Support System was needed to maintain fidelity to the evidence base during implementation? • 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, 18(5): 89-105, 1999.

  14. Design and Development of NetDSS

  15. Cross-functional Design Team • Bill Raney, RN – Depression Care Manager • Amanda Davis MA – Technical Writer • Chris Steven – Web programmer • Silas Williams – Web programmer • Richard Hedrick – Systems Analyst • Jeff Pyne, MD – Psychiatrist • John Fortney, PhD – Translator

  16. Scope • Users – Care Managers • Patients – PC patients with depression • Timing – Between PC visits • Purpose • Panel management • Trial management • Structured assessment • Decision support • Workload and Outcomes Reports

  17. Attributes • NetDCMS was designed to have most of the required features of a clinical information system as outlined in a recent article by Kilbourne and colleagues (2006) including: • Short training time, with uncluttered screens that are easy to navigate • Web-based • Use of drop menus and logic checks • Compliant with HIPAA standards and conforms to standards to internet security/encryption • Use of clinic reminders • Capability of creating individual care plans with self-management information and disease severity rating • Capacity to print out summary data on quality and other patient outcomes • Linked with, but not a substitute for electronic medical records • Supports multiple chronic illnesses • Kilbourne AM, McGinnis GF, Belnap BH, Klinkman M, Thomas M. The role of clinical information technology in depression care management. Adm Policy Ment Health. 2006 Jan;33(1):54-64.

  18. Features • NetDSS has the following functional capabilities: • patient registry and panel management • trial and phase management • encounter scheduler • decision support • progress note generator • workload report generator • NetDSS guides the care manager through a self-documenting and evidence-based patient encounter using scripts and self-scoring instruments which support: • patient education and activation • barrier assessment • comorbidity assessment • depression severity monitoring • suicide risk assessment • adherence monitoring • side-effect monitoring • self-management activities

  19. Registry Workload Report Database Care manager [ clinic [ provider [ patient ] ] ] Trial types [ phases [ success/failure ] ] Instrument scoring Outcomes tracking Automated Treatment Recommendations Decision Support Encounter Scheduler Assessments Progress Notes Story Board

  20. Story Board Evidence-Based Protocols User Interface Database Structure Trial Management Instruments and Scripts Panel Management Decision Support Assembling the Components

  21. Decisions • CPRS vs. stand-alone application • Target VA vs. private sector vs. both • Web-based vs. CD-ROM • Flexible vs. structured • User friendly vs. efficient

  22. Development Process • Rapid prototype-test-prototype product development cycles • Monthly planning meetings • Programming • User testing • Revisions & additions • Continuous beta test version (2 years) • Users Guide & Training Manual • Version 1.x with biannual updates (1.5 years)

  23. Current Users • VA RIPPLE Study (Contract CBOCs) • Little Rock, AR • Loma Linda, CA • Los Angeles, CA • VA HiTIDES Study (VA Medical Centers) • Little Rock, AR • Houston, TX • Atlanta, GA • NIMH OUTREACH Study (Federally Qualified Health Centers) • Little Rock, AR • Pine Bluff, AR • West Memphis, AR • Lepanto, AR • Corning, AR • Pochahontas, AR • Huntsville, AR • PC/MH Integration Initiative • Little Rock, AR • New Orleans, LA

  24. Web-Sites • Non-VA Version URL • https://www.netdss.net/ • VA Version URL • Send request from VA.gov email to: • virec@va.gov • John.Fortney@VA.gov

  25. NetDSS Demonstration

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