1. NetDSS Facilitating Implementation of a Depression Care Management Intervention Using Web-Based Decision Support
John Fortney, PhD
June 17, 2008
South Central MIRECC
HSR&D Center for Mental Health and Outcomes Research
HSR&D Mental Health QUERI
Central Arkansas Veterans Healthcare System

2. Funding Sources VA IIR 00-078-3 VA IMV 04-360 VA MNT 05-152
NIMH R01 MH

3. Clinical Background
75% of patients treated for depression receive care in primary care settings
20-50% of primary care patients stop taking medications in the first month of treatment
30-50% of primary care patients don’t respond to the initial medication
15-30% of primary care patients treated for depression receive guideline concordant care.

4. Components of Collaborative Care
Use of informatics to track critical processes
Use of clinical practice guidelines
Stepped care model
Ready access to mental health specialists
Delegation of key provider functions to non-physician members of a practice team
Care Management

5. Depression Care Management
Education and activation
Barrier assessment and resolution
Comorbidity assessment
Depression symptom monitoring
Suicide risk assessment
Medication adherence monitoring
Side-effects monitoring
Self Management goal setting and monitoring

6. Telemedicine-Based Collaborative Care for CBOCs
Offsite depression care team
Nurse care manager
Pharmacist
Psychiatrist
Telephones
Care manager encounters with patients at home
Interactive Video
Psychiatric evaluations with patients at CBOC
Electronic Medical Records (CPRS)
Communication among on-site PCPs and offsite depression care team

8. Effectiveness of TEAM Intervention
TEAM Study1,2 – Randomized effectiveness trial of telemedicine-based collaborative care in rural CBOCs
Increased medication adherence
Increased rates of response and remission
Increased health status
Increased patient satisfaction
Fortney JC, Pyne JM, Edlund MJ, Robinson DE, Mittal D, Henderson KL. Design and Implementation of the Telemedicine-Enhanced Antidepressant Management Study. General Hospital Psychiatry, 28(1): 18-26, 2006
Fortney JC, Pyne JM, Edlund MJ, Robinson DE, Mittal D, Henderson KL. A Randomized Trial of Telemedicine-Based Collaborative Care for Depression, Journal of General Internal Medicine, in press.

9. Medication Adherence Casemix-Adjusted Results
OR=2.1p=0.04
OR=2.7p<0.01

10. Response Casemix-Adjusted Results
OR=1.4p=0.18
OR=1.9p=0.02

11. Remission Case-mix Adjusted Results
OR=2.4p=0.02
OR=1.8p=0.14

12. Mental Health Component (MCS) Casemix-Adjusted Results

13. Satisfaction Casemix-Adjusted Results
OR=1.8p=0.01
OR=1.7p=0.03

14. Implementation Research
Partners In Care study
Fidelity to the care manger protocol was lower than anticipated
Computerized tracking system was recommended as a result1.
RIPPLE Study
Implement telemedicine-based collaborative care in contract CBOCs.
Decision Support System was needed to maintain fidelity to the evidence base during implementation?
Rubenstein LV, Jackson-Triche M, Unutzer J, Miranda J, Minnium K, Pearson M, Wells K. Evidence-Based Care for Depression in Managed Primary Care Practices, Health Affairs, 18(5): , 1999.

15. Design and Development of NetDSS

16. Cross-functional Design Team
Bill Raney, RN – Depression Care Manager
Amanda Davis MA – Technical Writer
Chris Steven – Web programmer
Silas Williams – Web programmer
Richard Hedrick – Systems Analyst
Jeff Pyne, MD – Psychiatrist
John Fortney, PhD – Translator

17. Scope Users – Care Managers Patients – PC patients with depression
Timing – Between PC visits
Purpose
Panel management
Trial management
Structured assessment
Decision support
Workload and Outcomes Reports

18. Attributes
NetDCMS was designed to have most of the required features of a clinical information system as outlined in a recent article by Kilbourne and colleagues (2006) including:
Short training time, with uncluttered screens that are easy to navigate
Web-based
Use of drop menus and logic checks
Compliant with HIPAA standards and conforms to standards to internet security/encryption
Use of clinic reminders
Capability of creating individual care plans with self-management information and disease severity rating
Capacity to print out summary data on quality and other patient outcomes
Linked with, but not a substitute for electronic medical records
Supports multiple chronic illnesses
Kilbourne AM, McGinnis GF, Belnap BH, Klinkman M, Thomas M. The role of clinical information technology in depression care management. Adm Policy Ment Health Jan;33(1):54-64.

19. Features NetDSS has the following functional capabilities:
patient registry and panel management
trial and phase management
encounter scheduler
decision support
progress note generator
workload report generator
NetDSS guides the care manager through a self-documenting and evidence-based patient encounter using scripts and self-scoring instruments which support:
patient education and activation
barrier assessment
comorbidity assessment
depression severity monitoring
suicide risk assessment
adherence monitoring
side-effect monitoring
self-management activities

20. Story Board Database Registry Encounter Scheduler Assessments
Care manager [ clinic [ provider [ patient ] ] ]
Trial types [ phases [ success/failure ] ]
Instrument scoring
Outcomes tracking
Automated Treatment Recommendations
Registry
Encounter
Scheduler
Assessments
Workload Report
Progress Notes
Decision Support

21. Evidence-Based Protocols Instruments and Scripts
Assembling the Components
Story Board
Database Structure
User Interface
Evidence-Based Protocols
Trial Management
Instruments and Scripts
Panel Management
Decision Support

22. Decisions CPRS vs. stand-alone application
Target VA vs. private sector vs. both
Web-based vs. CD-ROM
Flexible vs. structured
User friendly vs. efficient

23. Development Process
Rapid prototype-test-prototype product development cycles
Monthly planning meetings
Programming
User testing
Revisions & additions
Continuous beta test version (2 years)
Users Guide & Training Manual
Version 1.x with biannual updates (1.5 years)

24. Current Users VA RIPPLE Study (Contract CBOCs) Little Rock, AR
Loma Linda, CA
Los Angeles, CA
VA HiTIDES Study (VA Medical Centers)
Houston, TX
Atlanta, GA
NIMH OUTREACH Study (Federally Qualified Health Centers)
Pine Bluff, AR
West Memphis, AR
Lepanto, AR
Corning, AR
Pochahontas, AR
Huntsville, AR
PC/MH Integration Initiative
New Orleans, LA

25. Web-Sites Non-VA Version URL VA Version URL https://www.netdss.net/
Send request from VA.gov to:

26. NetDSS Demonstration