CHIACC: Creating HealtheVet

Informatics Applications for Collaborative Care

Amy N. Cohen, PhDVA Desert Pacific MIRECC

Chronic Illness Cost: dollars and disability 100 million with at least 1 chronic illness 30 million disabled 75% of all healthcare costs; rising Seniors hardest hit; 96% of all Medicare

costs Mental illness incidence is rising; high costs

Community Health System Resources and Policies ------ Organization of Health Care

Self-Management

Support

Delivery System Design

Decision Support

Clinical Information

Systems

Informed, Activated Patients & Caregivers

Prepared, Proactive

Practice TeamCollaborative Care

Functional and Clinical Outcomes

From: E.H. Wagner & RWJF Improving Chronic Illness Care Initiative

Improving Care for Chronic Illness

How can IT help? Support collection of standard data Support self-management and PHR Organize Data Ease Communication Provider feedback Highlight patient-level and population-level issues Assist with reorganization of care

Charge to use IT and Collaborative Care

VA Action Agenda (Goal 6): Technology is used to access MH care and information

VA MH Executive Steering Committee: “endorse” collaborative care of MH services in all VA Primary Care clinics

CHIACC Objectives

Develop, evaluate and implement software to support improving chronic illness care that is

rated high in usability improves efficiency interface with MyHealtheVet and CPRS-R

CHIACC TeamLos Angeles, California

Alexander S. Young, MD, MSHS (Co-PI)Amy Cohen, PhDJennifer Pope, BS

Rebecca Shoai, MSW, MPHPaul Jung

Seattle, WashingtonEdmund Chaney, PhD (Co-PI)

Laura Bonner, PhD Laura Rabuck, MPIA

Carol Simons, BSYoulim Choi

Oregon Health & Science University, PortlandDavid Dorr, MD, MS

VIReCRuth Perrin, MA

Little Rock VAJohn Fortney, PhD

Funded by VA HSRD and QUERI

CHIACC Steering Committee

Hank RappaportTom CraigMary GoldsteinKaty LysellPaul Nichol

Allan FinkelsteinSusan McCutcheonJeff SmithLisa RubensteinRuth Perrin

CHIACC Methods

Phase 1a: Literature ReviewPhase 1b: Achieve expert consensus on

informatics support requirements for chronic illness care

Phase 2: Design and test software module

Phase 3: Implement software and conduct usability evaluation

Phase 1a:Literature Review Searched PubMed and business databases

on key concepts; 1996-2005 109 articles reviewed 112 information systems Chronic diseases targeted:

Diabetes 43% Heart Disease 37% Mental Illness 23%

Literature Review Conclusions Positive results (improvement in care process or

clinical outcomes) associated with Inclusion in an electronic medical record (EMR) Population management Specialized decision support Electronic scheduling Personal health records

Barriers to building systems Costs; data privacy and security; failure to consider

workflow

Use Case Models We developed Use Case Models for

collaborative care of depression, schizophrenia, diabetes, and a case with comorbid disorders

Presented to Expert Panel; iterative process to finalize Use Case Models

Use Case Model Use Case Model describes complete

system functionality Used not only for requirements capture, but

all along the software development process: Programmers create the prototype based on UC Developers review each successive prototype for

conformance to UC Field testing ensures the prototype correctly implements

the UC

Use Case Detail Start with a short, step-by-step description

of the use-case flow of events, and gradually make it more detailed.

Describe the trigger that activates the use case.

Describe how the use case terminates Describe what will reside inside the system,

and what will reside outside the system.

Use Case Detail (con’t) Describe the interaction between use

case and actors. Describe how the use case exchanges

data with an actor. Describe any optional situations in a use

case's flow of events

Phase 1b:Expert Panel Experts from VA, SAMHSA, Industry Panel met in Los Angeles, Sept 2005

Literature Review and Use Case Models

Expert Panel ConsensusAcross Diseases Recovery-oriented approach

patient-centered

Key outcomes measurements to provider at time of clinical encounter

Treatment plan sequential and comprehensive

Expert Panel ConsensusDepression

1. Patient screening --PHQ-9 as a lab test--Scores graphed against meds & encounters--Scores accessible from anywhere in record

2. Ensure diagnosis is on problem list.

Expert Panel ConsensusSchizophrenia

1. Routine assessment of critical outcomes--performance measures linked to appropriate

action

2. Automatic scoring algorithms --utilizing routine assessment data

Expert Panel ConsensusDiabetes1. Progress note templates

--with functionality--include next steps given data

2. Flow-sheets --track steps in care over time

3. Scheduling flexibility--Long-term “tickler” file

Expert Panel ConsensusComorbid Cases

1. Treatment Plan--interactive, sequential and comprehensive--shared across sites nationally

2. Standard codes across all sites

Phase 2: Design Software Module Illness self-management

In clinic: tablets or kiosks (PAS) At home: PHR

Care management desktop Messaging Quality Reports

Phase 2b: Test Software Module Usability with patient Usability with providers Qualitative interviews

Iterative Process---usability; revamp system; conformance to UC; usability; revamp….etc

Conclusions

CHIACC is an example of the iterative process of design necessary for informatics development

Literature on the subject is largely non-experimental

Experts agree on fundamental components of an IT system to support collaborative care

CHIACC module is in development; early reports from usability testing are positive

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, 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.

Dorr DA, Bonner L, Cohen AN, Shoai R, Perrin R, Chaney E, Young AS: (in press, 2007). Informatics systems which promote high quality, comprehensive care for chronic illness: A literature review. Journal of the American Medical Informatics Association.

Niv N, Cohen AN, Mintz J, Ventura J, & Young AS: (in press, 2007). The Validity of Using Patient Self-Report to Assess Psychotic Symptoms in Schizophrenia. Schizophrenia Research.

Acknowledgements

Acknowledgements– VA HSR&D and QUERI (MHS 03-218, CPI 99-383, MNT 03-213)

–VA Desert Pacific Mental Illness Research, Education and Clinical Program (MIRECC)

For further information–Amy N. Cohen, PhD

–MIRECC, West Los Angeles VA Healthcare Center,11301 Wilshire Blvd. (210A), Los Angeles CA 90073

–Amy.Cohen@va.gov