Using Clinical Reminders Patient List functionality to identify patients at risk for suicide or self

1
Using Clinical Reminders Patient List
functionality to identify patients at risk for
suicide or self harm

• Carol Achtmeyer, MN ARNP
• Kathleen Lysell, Psy.D
• VA Quality Enhancement Research Initiative
• VA Health Services Research Development
• VA Center of Excellence in Substance Abuse
  Treatment Education
• Office of Mental Health Services
• carol.achtmeyer_at_va.gov

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Background

• Identification of Veterans at risk of suicide is
  a top VA priority
• The current depression Performance Measure
  requires a suicide assessment for patients with a
  positive PHQ2, PHQ9 or any report of suicidal
  thoughts on PHQ9 item 9
• Clinical Reminders (CR) Patient Lists can create
  lists of patients with specific characteristics
  and display clinical information for triage and
  follow up

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Background

• New functionality added to Clinical Reminders
  Patient Lists (PXRM2.06) and the Mental Health
  Assistant (YS5.0185) in January 2008 allows
  creation of a patient list based on a single
  question response in a MHA screen
• This session will demonstrate how to build a list
  to identify patients who report suicidal thoughts
  on question 9 of the PHQ9

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Session Goals

• Demonstrate how to build list of patients at risk
  for suicide based on reports of suicidal thoughts
  in the PHQ9 depression screen
• Demonstrate how to add clinical data to list that
  may assist in triage and follow up of these
  patients
• Demonstrate (brief) how to export resulting data
  to Excel

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• The presentation today will focus on the PHQ9,
  however, the steps shown here can be applied to
  any of the MHA tests and many CR finding items

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Defining the Patient List components

• Sample
• Patients with thoughts of self harm as reported
  on the PHQ9 AND
• No documentation of suicide assessment, as
• defined by health factors and a progress note
  title
• Report Display
• Patient name, telephone number and SSN
• PHQ 9 total score (MHA PHQ9)
• PHQ 9 question 9 response (MHA PHQ9)
• Alcohol use screen score (MHA AUDC)

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Measure PHQ9 Report of Suicidal Thoughts
PHQ9 Question 9

• Over the past 2 weeks, how often have you been
  bothered
• by any of the following problems Thoughts that
  you would
• be better off dead or hurting yourself in some
  way?
• Not at all
• Several days
• More than half the days Positive
  responses
• Nearly every day

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Measure PHQ9 Report of Suicidal Thoughts

• Reminder Term for PHQ9 Q9 Pos includes the three
• positive response items. This will be the basis
  of the
• patient sample
• Finding Item PHQ9 (FI(1)MH(42))
• Finding Type MH TESTS AND SURVEYS
• MH Scale 419 - Total
• Condition I V("R",9)"Several
  days"
• Finding Item PHQ9 (FI(2)MH(42))
• Finding Type MH TESTS AND SURVEYS
• MH Scale 419 Total
• Condition I V("R",9)"More than
  half the days"
• Finding Item PHQ9 (FI(3)MH(42))
• Finding Type MH TESTS AND SURVEYS
  
• MH Scale 419 - Total
• Condition I V("R",9)"Nearly every
  day"

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Measure Suicide Risk Assessment Done

• Patients who have documentation of suicide risk
  assessment are NOT included on the list
• Documentation of assessment is defined as the
  presence of either of the following
• Health Factors linked to suicide risk assessment
  in depression/PTSD follow-up CRs
• HOPELESSNESS PRESENT/FUTURE
• NO HOPELESSNESS
  
• A Progress Note Title called Mental Health
  Triage Evaluation Note that includes a suicide
  risk assessment template

Health Factor and Note Title names may vary by
facility
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Documentation of Suicide Risk Assessment

• Reminder term for Suicide Risk Assessment
  includes these three findings
• Finding Item HOPELESSNESS
  PRESENT/FUTURE
• Finding Type HEALTH FACTOR
• Health Factor Category SUICIDE RISK
  SCREEN
• Include Visit Data YES if yes,
  adds encounter info to
• 
  demographic data
• Finding Item NO HOPELESSNESS
• Finding Type HEALTH FACTOR
• Health Factor Category SUICIDE RISK
  SCREEN
• Finding Item VA-PROGRESS NOTE
• Finding Type REMINDER COMPUTED FINDING
• Condition I V"MENTAL HEALTH TRIAGE
  EVALUATION NOTE"
• Computed Finding Parameter MENTAL
  HEALTH TRIAGE
• 
  EVALUATION NOTE

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Reminder Terms to Display Data

• Reminder Terms for the AUDIT-C and PHQ9 scores be
  used to insert data related to a patients
  alcohol use and severity of depression
• Reminder Term 1 - AUDC Score
• Finding Item AUDC (FI(1)MH(5)Finding Type
  MH TESTS AND SURVEYSMH Scale 276 Total
• Reminder Term 2 - PHQ9 Score
• Finding Item PHQ9 (FI(1)MH(42))Finding Type
  MH TESTS AND SURVEYSMH Scale 419 - Total

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Building patient list Overview
Hard CodedDemographic Data
Insert Finding CSUB data
Run List with Demographic Data
Create Patient List
Rule Set (set operators for each sequence)
Create Finding Rule for each Reminder Term
Create Reminder Terms for each Finding Item
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Building Patient List Rule Set

• How each sequence is set up in the Rule Set
  determines the function of each item
• Four different operators are available
• Add patient
• Select
• Remove
• Insert Finding
• sets display of clinical data

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Building Patient List Rule Set

• Sequence 5
• Operation ADD PATIENT
• List Rule PHQ9 Q9 (FR)
• Rule Type FINDING RULE
• Reminder Term PHQ9 Q9 POS (RT)

Sequence 10 Operation REMOVE
List Rule SUICIDE ASSESS FINDINGS (FR) Rule
Type FINDING RULE Reminder Term SUICIDE ASSESS
(RT)
Sequence 15 Operation INSERT FINDING List Rule
AUDC SCORES (FR) Rule Type FINDING RULE Reminder
Term VEHU AUDC SCORE (RT)
Sequence 20 Operation INSERT FINDING List Rule
PHQ9 Scores (FR) Rule Type FINDING RULE
Reminder Term VEHU PHQ9 Q9 POS (RT)
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Building Patient List Demographic Data

• List Name VEHU INSERT PHQ9 AUDC HF'S
• Created 06/17/2008_at_132225 Creator
  TEST,CAC
• Source List Rule - PHQ9 Q9 POS
• Number of patients 4
• . Patient Name DFN
  .
  
• 1 ONE, PATIENT 0000000
  
• 2 TWO, PATIENT 0000000
  
• 3 THREE, PATIENT 0000000
• 4 FOUR, PATIENT 0000000
  
• CV Change View
  ED Edit Patient List
• HSA Health Summary All
  USR View Users
• HSI Health Summary Ind
  QU Quit
• DEM Demographic Report type DEM for data
  display options
• Select Item Next Screen// DEM

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Building Patient List Demographic Data

• Select from the following patient data
• 1 - AUDIT-C SCORES,"FINDING NAME"
• 2 - AUDIT-C SCORES,"MH TEST"
• 3 - AUDIT-C SCORES,"R",1
• 4 - AUDIT-C SCORES,"R",2
• 5 - AUDIT-C SCORES,"R",3
• 6 - AUDIT-C SCORES,"S",276
• 7 - AUDIT-C SCORES,"SCALE NAME"
• 8 - AUDIT-C SCORES,"VALUE"
• 9 - PHQ9 SCORES),"MH TEST"
• 10 - PHQ9 SCORES,"R",1
• 11 - PHQ9 SCORES,"R",10
• 12 - PHQ9 SCORES,"R",2
• 13 - PHQ9 SCORES,"R",3
• 14 - PHQ9 SCORES,"R",4
• 15 - PHQ9 SCORES,"R",5
• 16 - PHQ9 SCORES,"R",6
• 17 - PHQ9 SCORES,"R",7

Fields set to insert finding will show on this
list
The items chosen will give the name of the MH
test, score and the response to question 9 of the
PHQ9 Items will display in the order selected
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Patient List as ASCII Text
The results display as ASCII text with
delimiters. This text is copied and saved into a
notepad file.

• Patient Demographic Report
• Patient List VEHU PHQ9 Q9 POS W/DATA
• Created on Jun 17, 2008_at_132225
• PATIENTPHONE NUMBERSSNAUDIT-C SCORES,"FINDING
  NAME"AUDIT-C SCORES,
• "VALUE"PHQ9 SCORES,"FINDING NAME"PHQ9
  SCORES,"VALUE"PHQ9
• SCORES,"R",9\\
• PATIENT,ONE(111)111-1111000-00-1234AUDC11PHQ9
  21Nearly every day\\
• PATIENT,TWO(111)111-1112000-00-1235AUDC7PHQ9
  17Several days\\
• PATIENT,THREE(111)111-1113000-00-1236AUDC1PHQ
  922Several days\\
• PATIENT,FOUR(111)111-1114000-00-6234AUDC6PHQ9
  12More than half the days\\
• PATIENT,FIVE(111)111-1115000-00-1434PHQ917S
  everal days\\
• PATIENT,SIX(111)111-1116000-00-1234AUDC0PHQ9
  24Several days\\
• PATIENT,SEVEN(111)111-1117000-00-1264AUDC10PH
  Q927Nearly every day\\
• PATIENT,EIGHT(111)111-1118000-00-6234AUDC8PHQ
  917Several days\
• Data is fictitious

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Creating Excel Table from ASCII text
ASCII text file
Patient Demographic Report Patient List VEHU
PHQ9 Q9 POS W/DATA Created on Jun 17,
2008_at_132225 PATIENTPHONE NUMBERSSNAUDIT-C
SCORES,"FINDING NAME"AUDIT-C SCORES, "VALUE"PHQ9
SCORES,"FINDING NAME"PHQ9 SCORES,"VALUE"PHQ9
SCORES,"R",9\\ PATIENT,ONE(111)111-1111000-00-1
234AUDC11PHQ921Nearly every
day\\ PATIENT,TWO(111)111-1112000-00-1235AUDC
7PHQ917Several days\\ PATIENT,THREE(111)111-1
113000-00-1236AUDC1PHQ922Several
days\\ PATIENT,FOUR(111)111-1114000-00-6234AUD
C6PHQ912More than half the days\\ PATIENT,FIV
E(111)111-1115000-00-1434PHQ917Several
days\\ PATIENT,SIX(111)111-1116000-00-1234AUDC
0PHQ924Several days\\ PATIENT,SEVEN(111)111-
1117000-00-1264AUDC10PHQ927Nearly every
day\\ PATIENT,EIGHT(111)111-1118000-00-6234AUD
C8PHQ917Several days\
Use Import command in Excel
Excel display (after editing headings)
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Technical Issues to consider

• Not all CR finding items can be used to display
  data, must be csub findings
• MH test dates not yet available in data display
• Complex patient sample definition
• Use reporting CR to define sample
• Patient Lists generated from CR reports can also
  display data requires some additional steps
• General Patient List Training
• VEHU 2006 Class 309H

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Process Issues to consider

• Who is the audience for this list?
• Essential to have identified process in place to
  use the data
• Who will run the list?
• How often will list be run?
• Who is responsible for following up the
  information?
• How will data be stored securely?

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Questions?Thoughts?Ideas?