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Incorporating Behavioral Health in the EHR to Improve Care. Insitute of Medicine | November 25, 2013 Brigid McCaw, MD, MS, MPH, FACP Medical Director, Family Violence Prevention Program The Permanente Medical Group. Health Risk Factors 2.0 . Behavioral Health is essential to health
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Incorporating Behavioral Health in the EHR to Improve Care Insitute of Medicine | November 25, 2013 Brigid McCaw, MD, MS, MPH, FACP Medical Director, Family Violence Prevention Program The Permanente Medical Group
Health Risk Factors 2.0 Behavioral Health is essential to health • Prevention works • People recover • Treatment is effective Substance Abuse and Mental Health Services Administration (SAMHSA)
BIG FOUR for Primary Care Depression Anxiety Disorders Substance Misuse Family Violence
Identifying Depression and Anxiety • Symptoms of depression, anxiety, and functioning problems combine to yield a “Global Distress Score” • Adult Outcomes Questionnaire (AOQ) includes PHQ-9, GAD-2 and functioning items • Serves as both screener and progress monitor • Available in paper, on-line, or by secure message • Used in adult medicine, women’s health, specialty mental health, and health education classes
Screening, Brief Intervention, and Referral to Treatment (SBIRT) “Alcohol as a Vital Sign” Began June 2013. All adult primary care patients (≥ 18 y.o.) now screened annually with evidence-based screener. Physicians provide brief advice or referral to Chemical Dependency treatment as appropriate.
Alcohol Screening: prompt in EHR Logic: Will appear once a year (or at six months if prior positive screening ). The first question is gender & age specific.
Alcohol Screening Questions • Sensitivity/ Specificity at detecting Unhealthy Use: 82% / 79% • Smith, 2009, J Gen Intern Med • NIAAA, 2005 “Helping Patients Who Drink Too Much”
Alcohol SBIRT Workflow *Vinson, 2007
BIG FOUR for Primary Care Depression Anxiety Disorders Substance Misuse Family Violence
Comparison to Other Life-Threatening Conditions Affecting Women In the US, each year
IPV screening and counseling should be core part of women’s health services Women’s Preventive Health Care Services Committee Universal screening for childbearing-age women recommended
The KP Systems-Model Approach Inquiry and Referral On-site Services Leadership and Oversight Supportive Environment Community Linkages “Making the right thing easier to do”
8-fold Increase in IPV Identification Largely in primary care and mental health departments Members Diagnosed with Intimate Partner Violence, 2000-2013 8090 { Emergency Dept. & Urgent Care Mental Health Primary Care 1022 {
Improving IPV Inquiry Reminders embedded in Progress Note
Improving IPV Documentation, Intervention & Referral • Smart phrases (clinic note with essential elements) • Smart set (includes note, orders, referral, followup) • Danger/lethality assessment questionnaire • Care Pathway for ED, primary care and MH • Facility specific referral protocol • Intranet resource site: “abuse and assault website”
BH in Primary Care Must Address Clinician AND Patient Concerns The doctor: • How do I ask about BH issues? • What do I do when the answer is “yes”? • The patient: • If I disclose, what will happen ? • How will this benefit my health?
Documentation of BH Issues in EHR Concerns: safety, privacy, stigma, visibility, discrimination Benefits: • Facilitates coordination of care • Prompts for follow-up and ongoing intervention • Allows other clinicians to reinforce intervention • Allows other clinicians to better understand what may underlie current medical conditions and adherence • Safety • Normalizing, removes stigma
What BH issues need to be next? What should that look like? Integrated BH “screening” tool that has branched logic and is interactive Provides information for clinician and to patient Adverse Childhood Experiences Adult Abuse and Trauma
Contact Information Brigid McCaw, MD, MS, MPH, FACP Medical Director, Family Violence Prevention Program The Permanente Medical Group Brigid.McCaw@kp.org 510-987-2035
