CHIACC: Creating HealtheVet Informatics Applications for Collaborative Care Amy N. Cohen, PhD VA 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 Team Collaborative 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 Team Los Angeles, California Alexander S. Young, MD, MSHS (Co-PI) Amy Cohen, PhD Jennifer Pope, BS Rebecca Shoai, MSW, MPH Paul Jung Seattle, Washington Edmund Chaney, PhD (Co-PI) Laura Bonner, PhD Laura Rabuck, MPIA Carol Simons, BS Youlim Choi Oregon Health & Science University, Portland David Dorr, MD, MS VIReC Ruth Perrin, MA Little Rock VA John Fortney, PhD Funded by VA HSRD and QUERI

CHIACC Steering Committee Hank Rappaport Tom Craig Mary Goldstein Katy Lysell Paul Nichol Allan Finkelstein Susan McCutcheon Jeff Smith Lisa Rubenstein Ruth Perrin

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 module Phase 3: Implement software and conduct usability evaluation

Phase 1a: Literature Review Searched PubMed and business databases on key concepts; 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 Consensus Across Diseases Recovery-oriented approach patient-centered Key outcomes measurements to provider at time of clinical encounter Treatment plan sequential and comprehensive

Expert Panel Consensus Depression 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 Consensus Schizophrenia 1. Routine assessment of critical outcomes --performance measures linked to appropriate action 2. Automatic scoring algorithms --utilizing routine assessment data

Expert Panel Consensus Diabetes 1. 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 Consensus Comorbid 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: 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: 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

– VA HSR&D and QUERI (MHS , CPI , MNT ) –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, Wilshire Blvd. (210A), Los Angeles CA