Implementation and Dissemination of Alcohol Screening and Follow-up Using Tools in CPRS/VistA

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Implementation and Dissemination of Alcohol
Screening and Follow-up Using Tools in CPRS/VistA

• Katharine Bradley, MD
• Dan Kivlahan, PhD
• Carol Achtmeyer, MN, ARNP
• Emily Williams, MPH
• Gwen Lapham, MSW
• Supported by NW HSRD RWJ Foundation SUD QUERI
  CESATE
• VA Puget Sound

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Overview

• Implementation of 2 Two CPRS Clinical Reminders
• Alcohol screening
• Follow-up positive alcohol screens

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Outline

• Background alcohol misuse
• VistA/CPRS components and approaches used
• Clinical reminders
• Health factors
• Mental health package
• Clinical informatics expert
• Case Study 1 - Screening
• Local ? National
• Case Study 2 - Brief alcohol counseling
• Local ? Regional ? National
• Next steps

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Background

• Alcohol misuse is common large health burden
• Evidence supports preventive focus
• Brief alcohol counseling interventions effective
• Target population patients with risky drinking
• Advice and feedback decrease drinking
• 3rd highest US Prevention Priority-Solberg 2008
• Limited implementation of brief alcohol
  counseling

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Background

• Alcohol Screening in VA Prior to 2003
• Original performance measure (PM)
• PM required any standardized screen
• Almost all used CAGE
• Identifies lifetime alcohol use disorders
• Does not indicate if patients drink
• Not the target population for brief alcohol
  counseling

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Incremental Implementation

• 2000 AUDIT-C clinical reminder (CR) - 1 site
• 2001 Development CR for Follow-up 1 site
• 2002 Pilot Study of Follow-up CR 1 site
• 2003 New screening Performance Measure
• 2003 National screening CR AUDIT-C
• 2004 Adoption of Follow-up CR by large VA
• 2007 Screening PM modified
• 2007 National PM for Follow-up Positive AUDIT-Cs
• 2008 National Follow-up CR disseminated

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Key Concepts

• Required for HIT implementation
• System and HIT readiness (at same time)
• Linkage between researchers/HIT developers and
  informatics, clinical, and QI leaders
• Clinical informatics expert on research team
• Creative financing not on project timeline
• Greenhalgh model (2004) has been helpful
  understanding success and failures

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CPRS/VistA Tools for Implementation Research

• Intro to Clinical Reminders (CRs)
• CPRS Clinical Reminders can
• Alert providers to clinical care due
• Educate providers
• Provide decision support
• Document care
• Be shared between facilities
• Provide data for performance monitoring
• Activated for specific providers
• CR reports can monitor in real time

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Intro to CPRS Clinical Reminders
Provider Opens Progress Note
Provider MAY open Reminders Window
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Intro to CPRS Clinical Reminders
Progress Note
Provider MAY choose to address follow-up for a
positive alcohol misuse screen
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Intro to CPRS Clinical Reminders
Clicking on Reminders Button and CR name brings
up reminder dialog
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Intro to CPRS Clinical Reminders
Decision Support
Health Factors are sent to VistA when boxes are
clicked
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CPRS/VistA Tools for Implementation Research

• Health factors
• Can be attached to specific actions in CRs and
  used to monitor CR activity
• Are not standardized, so vary across sites and
  over time
• Stored locally in VistA, in some regional data
  warehouses and CDW
• Mental Health Assistant (MHA)
• Standardized assessment instruments
• Scored automatically
• Standardized data
• Data stored in local VistA, eventually Pittsburg

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CPRS/VistA Tools for Implementation Research
CPRS GUI
Clinical Reminders
VistA Files
Health Factors
Prog.Notes
Pharmacy
Labs
MH Package
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Clinical Informatics Expert

• Prescribing clinician
• Familiar with basic VistA and CPRS functions
• Knew local programmers
• Entrepreneurial
• Initial role project-oriented
• Evolved to multiple roles
• Builds clinical reminders, order sets etc.
• Monitoring developments in CPRS
• Networking within informatics community
• Identify/develop data sources
• Obtaining VistA data

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Clinical Informatics Expert

• Staying on the cutting edge
• Attend annual VeHU conferences, online trainings
• Weekly calls on CPRS or Clinical Reminders
• American Informatics Medical Association (AMIA)
• Review research on VA CPRS
• Maintaining access to CPRS
• Service to local facility
• Beta test new CPRS software
• Creative Financing non-VA funding, Clinical COE
  (CESATE) and QUERI core funds

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Case Study 1

• Case Study 1
• Screening Clinical Reminder
• Local (2000-2007)
• National (2004-2008)

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Case Study 1 - Alcohol Screening

• AUDIT-C
• 3-item screen (0-4 each) sum to 0-12
• Identifies the target population for brief
  alcohol counseling
• Described/validated in VA outpatients 1998

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Case Study 1 - Alcohol Screening

• AUDIT-C into the MHA
• Papers shared with Office of Mental Health
• 2 AUDIT-Cs added to MHA (self-scoring)
• Technical problems with MHA AUDIT-C
• Could not be corrected locally

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Case Study 1 - Alcohol Screening

• Local Implementation of AUDIT-C
• 2000
• Local decision to use AUDIT-C
• Based on review of evidence
• Request for MH programmers to fix MHA AUDIT-C
• Meanwhile local AUDIT-C CR built not
  self-scoring
• AUDIT-C in MHA for years with no use

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Case Study 1 - Alcohol Screening

• National Implementation of AUDIT-C
• 2003
• Office of Quality and Performance (OQP) sought
  guidance for next steps
• Among VA patients who had 4 drinks/day
• 66 felt they needed services for drinking
• Only 17 reported they got needed services
• OQP educated need to screen for risky drinking

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Case Study 1 - Alcohol Screening

• Invitation to give key national presentations
• Quality Management Information Conferences (2)
• Performance Measures Work Group (PMWG)
• PMWG decides to require AUDIT-C in FY 2004
• National demand for new informatics tools for
  self scoring AUDIT-C

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Case Study 1 - Alcohol Screening

• OQP convened call develop AUDIT-C clinical
  reminder
• Content experts (researchers)
• Research clinical informatics expert
• National CR expert
• Associate Chief Consultant for MH Informatics
• OQP leader in charge of PM
• Barrier self scoring AUDIT-C still needed fixing

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Case Study 1 - Alcohol Screening

• Clinical informatics expert
• Knew problems with MHA AUDIT-Cs
• Boundary spanner
• Barrier AUDIT-C in MH package lacked response
  options for nondrinkers
• Led to 2 step clinical reminder
• Identify drinkers
• Administer AUDIT-C
• National expert built AUDIT-C CR
• CR made available nationally

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Case Study 1 - Alcohol Screening

• Passive diffusion AUDIT-C in MHA
• used 1.4 million times in 2004
• Lack of buy-in
• End-users not familiar with AUDIT-C
• New paradigm preventive counseling
• FAQ posted by OQP ? educated the field
• SHEP survey used to evaluate
• Problems in quality nondrinkers and under
  reporting
• Revised PM in 2007

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Case Study 1 - Alcohol Screening

• Facilitators
• System readiness
• Collaboration researchers, informatics
  clinical leaders
• HIT tool is available when system is ready
• Characteristics of the innovation ? diffusion
• Evaluation and feedback
• Comparison of survey clinical screening
• Resulted in revised Performance Measure

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Case Study 1 - Alcohol Screening

• Barriers
• HIT not ready when PM announced
• Decision made to use 2 step screening
  non-standard assessment of drinking
• Initially unprepared for educational need
• Problems with face validity of AUDIT-C
• Lack of provider buy-in
• Lack of awareness of the importance of how
  screening is completed (verbatim private
  non-judgmental)

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Case Study 2

• Follow-up Clinical Reminder
• Local (2001-2005)
• Regional (2004-2006)
• National (2008)

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Case Study 2A Follow-up Clinical Reminder

• Local Pilot
• Follow-up Clinical Reminder
• Version 1 (2001)
• Original idea
• Simple feedback of screening results to
  providers relied on CPRS programmers
• CPRS expert hired to help ? not feasible
• CPRS expert clinical reminders
• Version 1 clinical reminder content based on
  trials
• Assumed provider would do full assessment
• Focus groups

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Case Study 2A Follow-up Clinical Reminder

• Follow-up Clinical Reminder
• Version 1 (2001)
• Modifications after focus group feedback
• Simpler algorithm and help text
• Only advice initially required
• Escape option Will address at next visit
• Optional
• Assessment diagnostic criteria, labs, blood
  pressure, readiness to change
• Intervention patients goal, referral, etc.

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Case Study 2A Follow-up Clinical Reminder
Provider Education recommended drinking limits
Provider Education Components of BI
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Case Study 2A Follow-up Clinical Reminder

• Provides Decision Support
• Risk Stratify Assess prior treatment and whether
  drinking above limits
• Advise required to turn off clinical reminders
• Optional Document giving feedback on medical
  problems linked to alcohol use, further
  assessment, or referral

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Case Study 2A Follow-up Clinical Reminder
Facilitates documentation Each action clicked is
documented in progress note
Turns off clinical reminder if advice documented
Click Finish button
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Case Study 2A Follow-up Clinical Reminder

• Local Pilot
• Follow-up Clinical Reminder
• (2003-2005)
• Tested locally after revision
• Primary care providers did not routinely use CRs
• No specific training email announcement only
• Health factors from regional data warehouse
• Low rates of use 15
• Many noted would address alcohol at another visit

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Local Pilot (2003-2005)
Case Study 2A Follow-up Clinical Reminder

• Facilitators
• Clinical informatics expert
• Identified tools
• Built and reiteratively revised clinical reminder
• Early linkage with local end-users
• 11 observation and focus groups key
• Barriers
• VA providers hard to recruit for focus groups
• Low system readiness

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Case Study 2B Follow-up Clinical Reminder
Informal Regional Dissemination

• National implementation of AUDIT-C screening ?
• The field wanted help with follow-up
• National CR experts requested follow-up CR
• One expert
• Simplified and implemented the CR at 8 sites
• Shared with other sites
• Health factors simplified and changed
• Used CPRS CR Reports to track
• Submitted IRB application

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Case Study 2B Follow-up Clinical
ReminderInformal Regional Dissemination
Patients with Positive AUDIT-C whose
Provider Completed CR for Brief Alcohol Counseling
Bradley Substance Abuse 2007
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Case Study 2B Follow-up Clinical
ReminderInformal Regional Dissemination
Patients with Positive AUDIT-C whose
Provider Completed CR for Brief Alcohol
Counseling
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Case Study 2B Follow-up Clinical
ReminderInformal Regional Dissemination

• Evaluation
• CR reports provide no detail on parts of CR used
• CIE worked to get MHA data out of VistA (VeHU)
• National fileman expert wrote Fileman query
• CIE Tested locally, then sent to pilot site
• Pilot site built locally ? extracted data
• ASCII file? transferred server to server ?STATA
• Health factor data difficult to interpret
• CIEclinical informatics expert

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Case Study 2B Follow-up Clinical
ReminderInformal Regional Dissemination

• Facilitators
• System readiness
• Performance measure for screening created demand
  for Follow-up CR at some sites
• Primary care providers routinely used CR
• CIE - Informal informatics networks
• Improved/adapted clinical reminder
• 2nd Pilot 8 sites
• Allowed us to get data from that site
• Barriers
• Finding MHA data
• Health factor data edited not distinct names

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Case Study 2B-C Follow-up Clinical
ReminderImproving the CR for National
Dissemination

• Quality Improvement before Dissemination
• OQP consulted Follow-up EPRP measures (6/2006)
• Collaboration on Follow-up CR (5/2007)
• OQP and OMHS
• national CR expert CR
• But no formative evaluation of CR yet!
• How are providers using the CRs?
• What needs fixing?
• Hasty quality improvement interviews
• Creative financing CESATE

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Case Study 2C Follow-up Clinical
ReminderNational Dissemination

• Dissemination
• Clinical reminder adapted again
• Further simplified based on interviews
• Made consistent with performance measure
• Fall 2007 sites could request CR from Office of
  Primary Care-Mental Health integration
• Distributed nationally in CPRS CR patch 6,
  January 2008

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Case Study 2C Follow-up Clinical
ReminderNational Dissemination

• Change Over Time in
• Rates of Documented Brief Alcohol Counseling

Among Patients with AUDIT-C gt 5 ps lt 0.001
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Case Study 2C Follow-up Clinical
ReminderNational Dissemination

• Change Over Time in
• Rates of Documented Brief Alcohol Counseling

Among Patients with AUDIT-C gt 5 ps lt 0.001
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Case Study 2C Follow-up Clinical
ReminderNational Dissemination

• Change Over Time in
• Rates of Documented Brief Alcohol Counseling

Among Patients with AUDIT-C gt 5 ps lt 0.001
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Case Study 2C Follow-up Clinical
ReminderNational Dissemination

• Change Over Time in
• Rates of Documented Brief Alcohol Counseling

Among Patients with AUDIT-C gt 5 ps lt 0.001
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Next Steps

• Standardize follow-up CR for electronic
  monitoring
• Evaluate quality of brief alcohol counseling
• Compare documented advice patient report
• Evaluate changes in drinking after counseling
• Validate AUDIT-C as a measure of change
• Compare quality across implementation strategies
• B Yanos Primary care survey
• Work towards having MHA AUDIT-C
• interact with the pharmacy package
• inserted into pre-op templates
• Chronic management alcohol dependence in CPRS
• Patient lists, order sets, and templates

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Conclusions

• Challenges for Implementation
• Lack of system readiness
• Unanticipated opportunities ? quick fixes
• Lack of provider education
• Changes in leadership
• Research funding not well suited
• Clinical informatics expert keeping expertise
  while on a research team

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Conclusions

• Important Facilitators
• Strong evidence-base
• System readiness
• Collaboration between researchers quality
  improvement / clinical leaders
• Flexible funding and
• most of all
• Clinical informatics expert

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The End

• Thank You!
• Bryan Volpp
• Roxanne Rusch
• Lynette Nilan
• Dale Cannon
• Alan Finkelstein
• Katy Lysell
• Ira Katz
• Michael Mayo-Smith
• VA Puget Sound Informatics

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Original CR Tried to Replicate Elements in Trials
Case Study 2A Follow-up Clinical Reminder
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Case Study 2A Follow-up Clinical Reminder

• Follow-up Clinical Reminder
• Version 1 (2001)
• 3 Local Focus Groups
• Providers with variable needs
• Most did not want to assess at all
• Too much help text in CR
• Keep it simple