1. 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

2. 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)

3. BIG FOUR for Primary Care Depression Anxiety Disorders Substance Misuse Family Violence

4. 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

5. Adult Outcomes Questionnaire (AOQ)

6. Transition in Quality Measures: From Process to Outcome

7. 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.

8. 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.

9. Sensitivity/ Specificity at detecting Unhealthy Use: 82% / 79% Smith, 2009, J Gen Intern Med NIAAA, 2005 “Helping Patients Who Drink Too Much” Alcohol Screening Questions

10. Alcohol SBIRT Workflow *Vinson, 2007

11. BIG FOUR for Primary Care Depression Anxiety Disorders Substance Misuse Family Violence

12. Comparison to Other Life-Threatening Conditions Affecting Women New cases of breast cancer [2] 211,000 Number of women dying from cardiovascular disease [3] 484,000 Women who are injured from IPV [4] 2,000,000 In the US, each year

13. 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

14. The KP Systems-Model Approach Inquiry and Referral Supportive Environment Leadership and Oversight On-site Services Community Linkages “Making the right thing easier to do”

15. 8-fold Increase in IPV Identification Largely in primary care and mental health departments Members Diagnosed with Intimate Partner Violence, 2000-2013 1022 8090 { { Emergency Dept. & Urgent Care Mental Health Primary Care

16. Improving IPV Inquiry Reminders embedded in Progress Note

17. 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”

18. Abuse and Assault Site Connected to EHR

19. Online Training Tools for Clinicians

20. 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?

21. 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

22. 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

23. 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

24. Patient Education: Exam Room Poster