Optimizing Informatics Support for Collaborative Care: VA Smoking and Depression Treatment Examples Academy Health Boston June 28, 2005

Authors & Collaborators Edmund Chaney PhD, Laura Bonner PhD, Susan Vivell PhD, Colletta Austin MA, Scott Sherman MD and Colleagues VA HSR&D Mental Health QUERI VA VISNs 10, 16, 21, 22, 23 Clinicians, Informatics Specialists & Administrators VA HSR&D Centers of Excellence at Seattle, Sepulveda and Little Rock VA MIRECCS in VISNs 22, 20 & 16

Collaborative Care Clinical Information System Challenges VA CPRS is a state of the art HR system, evolving toward HealtheVet VistA What is missing to support chronic care? If more is necessary, how to add it? – Development & programming process – Dissemination and backup plans

What needs further development in CPRS? Integrated Mental Health assessment tools Panel management Team communication tools Patient self-management support Decision support for evidence-based treatment Program evaluation tools

How to Provide Missing Functions as CPRS Evolves? Balance development time, cost, feasibility, extensibility & transportability Options: – Local VistA extensions – Local external applications – Web-based, internet or VA intranet access – Combinations

6 Scott Sherman MD, VA VISNs 21 & 22 Clinicians & HSR&D Researchers California Smokers Helpline

Telephone Care Coordination to Improve Smoking Cessation Counseling Provider referral Research randomization Assessments Medication orders TeleQuit Care Coordinator Panel Management Quality and research reports

Menu options on VA VistA for TeleQuit

Local VistA Augmentation Counselors enter clinical and scheduling data into a VistA file Patient data objects created for selected fields Data automatically uploads into CPRS progress note templates Reports based on the VistA file facilitate cross- coverage and track clinical outcome, administrative and cost data

TeleQuit Consult – Providers may send a patient referral by entering a consult in CPRS

A summary of responses can be provided to the Helpline during a 3-way call Information Transferred to Helpline

TQCC can enter a request to send the Take Control or Decide guide for self- help patients Request for Smoking Cessation Guides

TQCC can send request for medication to the TeleQuit Nurse Practitioner and indicate contraindication(s) Medication Request Consult

TQCC can upload information from VISTA into CPRS to provide information regarding patients smoking history to the TeleQuit Nurse Practitioner Patient Progress Note

Augmented Functions: Streamlined Clinical Process: providers and the TeleQuit staff receive up-to-date information regarding: – Referrals to TeleQuit – Baseline information on patients smoking history Summary of patients responses – Requests for smoking cessation guides – Patient requests for medication – Clinical progress notes Quality Control: produces administrative reports to ensure that patients are contacted on a timely manner and quality care is provided

VA SUD QUERI Demonstration Project Results 2,900 referrals for smoking cessation in 10 months 45% of patients starting treatment were abstinent six months later – equal to or better than smoking cessation clinics Substantial savings per quitter compared to provider and clinic-based programs

Translating Initiatives for Depression into Effective Solutions (TIDES) Helps interested VA VISNs to locally adapt evidence-based collaborative depression care models – Formed partnerships with 4 VISNs – Conducted Expert Panels – Designed tools and providing training – Assisting with ongoing evaluation – Sustaining clinician-researcher partnerships

HOT SPRINGS BLACK HILLSSIOUX FALLS TWIN PORTS CANTON YOUNGSTOWN AKRON PENSACOLA BEAUMONT LUFKIN Prospective Sites Participating Sites TIDES Primary Care Clinic Sites NEW YORK WEST LA LONG BEACH PORTLAND SEATTLE Tentative Sites HOUSTON CINCINATTI SHREVEPORT VISN 23

TIDES Informatics Projects Depression Care Manager training aid – PsyOpSys Internet information site User-configurable CPRS consult and note templates – Similar to TeleQuit Depression Performance Measure tracking

Patient Self-Management, Provider & Organization Education Three Goals: – Support depression self-management – Depression treatment information for primary care clinicians – Up-to-date depression collaborative care information for Practice or Healthcare Organizations

TIDES Website Statistics (First 6 months of 2005) 9,180 visits (daily average of 52) 52,117 hits (daily average of 299) 4,581 total visitors 44% of visitors came from a referring site or search engine. Average of 3.9 pages viewed per visit.

Top Pages by Visit (2005)

Popular Pages 1. Homepage 2. Depression Info for Clinicians – Information on depression burden and treatability 3. The Cycle of Depression 4. Depression Info for Veterans – Basic information and links to other pages on symptoms, causes, and treatment 5. Description of Tides Projects – Goals and methods

Conclusions It is feasible and productive to augment VA CPRS to assist in the collaborative care of chronic conditions such as smoking and depression. Such augmentations help inform the continuing development of HealtheVet VistA and My HealtheVet.