CHIACC: Creating HealtheVet Informatics Applications for Collaborative Care

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CHIACC Creating HealtheVet Informatics
Applications for Collaborative Care

• Amy N. Cohen, PhD
• VA Desert Pacific MIRECC

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Chronic Illness Cost dollars and disability

• 100 million with at least 1 chronic illness
• 30 million disabled
• 75 of all healthcare costs rising
• Seniors hardest hit 96 of all Medicare costs
• Mental illness incidence is rising high costs

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Improving Care for Chronic Illness
Collaborative Care
Functional and Clinical Outcomes
From E.H. Wagner RWJF Improving Chronic
Illness Care Initiative
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How can IT help?

• Support collection of standard data
• Support self-management and PHR
• Organize Data
• Ease Communication
• Provider feedback
• Highlight patient-level and population-level
  issues
• Assist with reorganization of care

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Charge to use IT and Collaborative Care

• VA Action Agenda (Goal 6) Technology is used to
  access MH care and information
• VA MH Executive Steering Committee endorse
  collaborative care of MH services in all VA
  Primary Care clinics

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CHIACC Objectives

• Develop, evaluate and implement software
• to support improving chronic illness care that is
• rated high in usability
• improves efficiency
• interface with MyHealtheVet and CPRS-R

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CHIACC Team
Los Angeles, California Alexander S. Young, MD,
MSHS (Co-PI) Amy Cohen, PhD Jennifer Pope,
BS Rebecca Shoai, MSW, MPH Paul Jung
Seattle, Washington Edmund Chaney, PhD
(Co-PI) Laura Bonner, PhD Laura Rabuck,
MPIA Carol Simons, BS Youlim Choi
Oregon Health Science University,
Portland David Dorr, MD, MS VIReC Ruth Perrin,
MA Little Rock VA John Fortney, PhD
Funded by VA HSRD and QUERI
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CHIACC Steering Committee
Hank Rappaport Tom Craig Mary Goldstein Katy
Lysell Paul Nichol
Allan Finkelstein Susan McCutcheon Jeff
Smith Lisa Rubenstein Ruth Perrin
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CHIACC Methods

• Phase 1a Literature Review
• Phase 1b Achieve expert consensus on
  informatics support requirements for chronic
  illness care
• Phase 2 Design and test software module
• Phase 3 Implement software and conduct
  usability evaluation

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Phase 1aLiterature Review

• Searched PubMed and business databases on key
  concepts 1996-2005
• 109 articles reviewed
• 112 information systems
• Chronic diseases targeted
• Diabetes 43
• Heart Disease 37
• Mental Illness 23

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Literature Review Conclusions

• Positive results (improvement in care process or
  clinical outcomes) associated with
• Inclusion in an electronic medical record (EMR)
• Population management
• Specialized decision support
• Electronic scheduling
• Personal health records
• Barriers to building systems
• Costs data privacy and security failure to
  consider workflow

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Use Case Models

• We developed Use Case Models for collaborative
  care of depression, schizophrenia, diabetes, and
  a case with comorbid disorders
• Presented to Expert Panel iterative process to
  finalize Use Case Models

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Use Case Model

• Use Case Model describes complete system
  functionality
• Used not only for requirements capture, but all
  along the software development process
• Programmers create the prototype based on UC
• Developers review each successive prototype for
  conformance to UC
• Field testing ensures the prototype correctly
  implements the UC

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Use Case Detail

• Start with a short, step-by-step description of
  the use-case flow of events, and gradually make
  it more detailed.
• Describe the trigger that activates the use case.
  
• Describe how the use case terminates
• Describe what will reside inside the system, and
  what will reside outside the system.

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Use Case Detail (cont)

• Describe the interaction between use case and
  actors.
• Describe how the use case exchanges data with an
  actor.
• Describe any optional situations in a use case's
  flow of events

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Phase 1bExpert Panel

• Experts from VA, SAMHSA, Industry
• Panel met in Los Angeles, Sept 2005
• Literature Review and Use Case Models

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Expert Panel ConsensusAcross Diseases

• Recovery-oriented approach
• patient-centered
• Key outcomes measurements to provider
• at time of clinical encounter
• Treatment plan
• sequential and comprehensive

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Expert Panel ConsensusDepression

• Patient screening
• --PHQ-9 as a lab test
• --Scores graphed against meds encounters
• --Scores accessible from anywhere in record
• Ensure diagnosis is on problem list.

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Expert Panel ConsensusSchizophrenia

• Routine assessment of critical outcomes
• --performance measures linked to appropriate
  action
• Automatic scoring algorithms
• --utilizing routine assessment data

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Expert Panel ConsensusDiabetes

• Progress note templates
• --with functionality
• --include next steps given data
• Flow-sheets
• --track steps in care over time
• Scheduling flexibility
• --Long-term tickler file

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Expert Panel ConsensusComorbid Cases

• Treatment Plan
• --interactive, sequential and comprehensive
• --shared across sites nationally
• Standard codes across all sites

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Phase 2 Design Software Module

• Illness self-management
• In clinic tablets or kiosks (PAS)
• At home PHR
• Care management desktop
• Messaging
• Quality Reports

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Phase 2b Test Software Module

• Usability with patient
• Usability with providers
• Qualitative interviews
• Iterative Process---usability revamp system
  conformance to UC usability revamp.etc

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Conclusions

• CHIACC is an example of the iterative process of
  design necessary for informatics development
• Literature on the subject is largely
  non-experimental
• Experts agree on fundamental components of an IT
  system to support collaborative care
• CHIACC module is in development early reports
  from usability testing are positive

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References

• Young AS, Mintz J, Cohen AN Clinical computing
  using information systems to improve care for
  persons with schizophrenia. Psychiatric Services
  2004 55253-5
• Young AS, Mintz J, Cohen AN, Chinman MJ A
  network-based system to improve care for
  schizophrenia the medical informatics network
  tool (MINT). J Am Med Inform Assoc. 2004 11
  358-67.
• Young AS, Cohen AN, Mintz J A vignette in the
  chapter on information systems. In The Institute
  of Medicine, eds. Improving the Quality of Health
  Care for Mental and Substance-Use Conditions
  Quality Chasm Series. Washington DC National
  Academies Press 2005241-242.
• Dorr DA, Bonner L, Cohen AN, Shoai R, Perrin R,
  Chaney E, Young AS (in press, 2007).
  Informatics systems which promote high quality,
  comprehensive care for chronic illness A
  literature review. Journal of the American
  Medical Informatics Association.
• Niv N, Cohen AN, Mintz J, Ventura J, Young AS
  (in press, 2007). The Validity of Using Patient
  Self-Report to Assess Psychotic Symptoms in
  Schizophrenia. Schizophrenia Research.

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Acknowledgements
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• Acknowledgements
• VA HSRD and QUERI (MHS 03-218, CPI 99-383, MNT
  03-213)
• VA Desert Pacific Mental Illness Research,
  Education and Clinical Program (MIRECC)
• For further information
• Amy N. Cohen, PhD
• MIRECC, West Los Angeles VA Healthcare
  Center,11301 Wilshire Blvd. (210A), Los Angeles
  CA 90073
• Amy.Cohen_at_va.gov