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Overview. Chronic illnessinformatics to improve careCHIACC project (HSR
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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
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 Oregon Health & Science UniversityDavid Dorr, MD, MS Funded by HSRD and QUERIFunded by HSRD and QUERI
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