Title: NetDSS Facilitating Implementation of a Depression Care Management Intervention Using Web-Based Decision Support
1NetDSSFacilitating Implementation of
aDepression Care Management Intervention Using
Web-Based Decision Support
- John Fortney, PhD
- June 17, 2008
- South Central MIRECC
- HSRD Center for Mental Health and Outcomes
Research - HSRD Mental Health QUERI
- Central Arkansas Veterans Healthcare System
2Funding Sources
- VA IIR 00-078-3
- VA IMV 04-360
- VA MNT 05-152
- NIMH R01 MH076908-01
3Clinical 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 dont respond to
the initial medication - 15-30 of primary care patients treated for
depression receive guideline concordant care.
4Components 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
5Depression 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
6Telemedicine-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
7(No Transcript)
8Effectiveness 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.
9Medication Adherence Casemix-Adjusted Results
OR2.1p0.04
OR2.7plt0.01
10Response Casemix-Adjusted Results
OR1.4p0.18
OR1.9p0.02
11RemissionCase-mix Adjusted Results
OR2.4p0.02
OR1.8p0.14
12Mental Health Component (MCS) Casemix-Adjusted
Results
Plt0.01
P0.07
13Satisfaction Casemix-Adjusted Results
OR1.7p0.03
OR1.8p0.01
14Implementation 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)
89-105, 1999.
15Design and Development of NetDSS
16Cross-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
17Scope
- 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
18Attributes
- 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. 2006 Jan33(1)54-64.
19Features
- 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
20Story Board
21Assembling the Components
22Decisions
- CPRS vs. stand-alone application
- Target VA vs. private sector vs. both
- Web-based vs. CD-ROM
- Flexible vs. structured
- User friendly vs. efficient
23Development 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)
24Current Users
- VA RIPPLE Study (Contract CBOCs)
- Little Rock, AR
- Loma Linda, CA
- Los Angeles, CA
- VA HiTIDES Study (VA Medical Centers)
- Little Rock, AR
- Houston, TX
- Atlanta, GA
- NIMH OUTREACH Study (Federally Qualified Health
Centers) - Little Rock, AR
- Pine Bluff, AR
- West Memphis, AR
- Lepanto, AR
- Corning, AR
- Pochahontas, AR
- Huntsville, AR
25Web-Sites
- Non-VA Version URL
- https//www.netdss.net/
- VA Version URL
- Send request from VA.gov email to
- virec_at_va.gov
- John.Fortney_at_VA.gov
26NetDSS Demonstration