NetDSS Facilitating Implementation of a Depression Care Management Intervention Using Web-Based Decision Support

1
NetDSSFacilitating 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

2
Funding Sources

• VA IIR 00-078-3
• VA IMV 04-360
• VA MNT 05-152
• NIMH R01 MH076908-01

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 dont 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

7
(No Transcript)
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
OR2.1p0.04
OR2.7plt0.01
10
Response Casemix-Adjusted Results
OR1.4p0.18
OR1.9p0.02
11
RemissionCase-mix Adjusted Results
OR2.4p0.02
OR1.8p0.14
12
Mental Health Component (MCS) Casemix-Adjusted
Results
Plt0.01
P0.07
13
Satisfaction Casemix-Adjusted Results
OR1.7p0.03
OR1.8p0.01
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)
  89-105, 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. 2006 Jan33(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
21
Assembling the Components
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)
• 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

25
Web-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

26
NetDSS Demonstration