# Presentation: 285955

## 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

**Notes:**
Introductions....
Carol Achtmeyer is a Primary Care Nurse Practitioner who worked as a Clinical Applications Coordinator at VA Puget Sound and was instrumental in implementing CPRS at that facility in the late 1990’s.  She has continued her work in informatics mostly focusing on development of the CPRS clinical decision support tool called Clinical Reminders.  She has worked on our research team since 2001 and continues to practice in primary care as well.
GIM-research-QUERI
Addictions psych- CESATE- under OMHS – QUERI
GIM NP- CAC- recruited to research team in 2002? 10 % initially.... Increasing over time
Other key cast  of characters... 
Others BV, many others

## Overview

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

**Notes:**
CONTEXT: Informaticcs = weak tool alone

## 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** **

**Notes:**
CONTEXT: Informaticcs = weak tool alone
Focus facilitators and barriers

## 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

**Notes:**
CONTEXT: Informaticcs = weak tool alone
KB 2 components of brief alcohol counseling 

## 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 

- 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

- Background

**Notes:**
CR linked to MHA for CAGE

## 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

**Notes:**
**We had talked about putting the facilitator/barrier info here?? Can’t find it though. I can type it in if that’s what you still want**
Not represented by single project
Funding CDA
COE
CORE QUERI

## 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

**Notes:**
**We had talked about putting the facilitator/barrier info here?? Can’t find it though. I can type it in if that’s what you still want**
Not represented by single project
Funding CDA
COE
CORE QUERI

##  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

**Notes:**
Tools we used
Caveat: only a few of the many...
Templates
Clinical reminders patient lists
Pharmacy package warning lables...

## Intro to CPRS Clinical Reminders 

**Provider MAY open Reminders Window**

**Provider Opens Progress Note**

**Intro to CPRS Clinical Reminders **

**Notes:**
Triggered by positive AUDIT-C 
First, Reminder = misnomer
These clinical reminders only remind if the provider looks at what clinical reminders are due

## Intro to CPRS Clinical Reminders 

**Provider MAY choose to address follow-up for a positive alcohol misuse screen**

**Progress Note**

**Intro to CPRS Clinical Reminders **

## Intro to CPRS Clinical Reminders 

**Clicking on Reminders Button and CR name brings up reminder dialog**

**Intro to CPRS Clinical Reminders **

**Notes:**
This is busy, but we could animate it 

## Intro to CPRS Clinical Reminders 

**Decision Support**

**Health Factors are sent to VistA when boxes are clicked**

**Intro to CPRS Clinical Reminders **

## 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

- 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

-  CPRS/VistA Tools for Implementation Research

**Notes:**
Tools we used
“MH Package”

## VistA Files

- CPRS GUI

- Health Factors

- Prog.Notes

- Pharmacy

- Labs

- MH Package

-  CPRS/VistA Tools for Implementation Research

- Clinical
- Reminders

**Notes:**
Use of CPRS GUI generates data that are sent to and stored in VistA files.  In turn the data in these VistA files are displayed in CPRS

## 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

**Notes:**
System antecedents
Infrastructure: CPRS with clinical reminders 
Culture of performance monitoring
Screening for alcohol use disorders - 1990s
System readiness
Patients report need: Large Health Study
Primary care-mental health integration
Performance measure for screening and follow-up 
CPRS expert/primary care clinician
Co-investigator, although not reseacher
Builds clinical reminders 
Translates: researchers and HIT experts
Networks with national HIT experts
Monitors new tools and potential data sources

## 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

**Notes:**
System antecedents
Infrastructure: CPRS with clinical reminders 
Culture of performance monitoring
Screening for alcohol use disorders - 1990s
System readiness
Patients report need: Large Health Study
Primary care-mental health integration
Performance measure for screening and follow-up 
CPRS expert/primary care clinician
Co-investigator, although not reseacher
Builds clinical reminders 
Translates: researchers and HIT experts
Networks with national HIT experts
Monitors new tools and potential data sources

## 

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

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

- Case Study #1

## 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

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

- 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

- 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

- 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

**~ 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

- Case Study #1 - Alcohol Screening

**Notes:**
SAY BECAUSE HEALTH FACTORS.... 
Lost standardized data

## 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 

**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

- Case Study #1 - Alcohol Screening

**Notes:**
OQP saw our research...
Called for help re how to implement evidence-based follow-up to the CAGE

## 
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 

- 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

- Case Study #1 - Alcohol Screening

**Notes:**
Instant and overwhelming
Replace self scoring CAGE

## 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

- 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

- Case Study #1 - Alcohol Screening

**Notes:**
This is an example were system readiness preceded adequate development of the informatics tool.  
K Bradley MD; D. Kivlahan PhD – content experts
Carol Achtmeyer ARNP – clinical informatics  
Bryan Volpp, MD – national CR developer
Bonnie Collins, PA – in charge of PM at OQP
Dale Cannon, PhD – Associate Chief Consultant for MH Informatics in Office of MH

Kathy Bradley MD – content expert
Dan?
Carol Achtmeyer ARNP – informatics (boundary spanner)
Bryan Volpp, MD – national clinical reminder developer
Bonnie Collins, OQP – in charge of performance measure
Dale Cannon – Associate Chief Consultant for MH informatics

## Clinical informatics expert
Knew problems with MHA AUDIT-C’s
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

- Knew problems with MHA AUDIT-C’s
- 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

- Case Study #1 - Alcohol Screening

**Notes:**
Local clinical informatics expert played key role 
Familiar with errors in MHA AUDIT-C 
Translated: informatics experts & researchers
AUDIT-C in MH package lacked response options for nondrinkers 2 step process
Establish if patient drinks
Administer AUDIT-C to drinkers
B. Volpp built Clinical Reminder
“Diffused” nationally
AUDIT-C in MHA used 1.4 million times in 2004
AUDIT-C added to SHEP Pt. satisfaction survey
Later evaluated  adapted performance measure

THIS IS TOO BUSY

Carol
Knew AUDIT-C was in MHA
Noted errors
Translated between informatics experts and researchers
AUDIT-C in MH package lacking response options for nondrinkers
Only administer only to drinkers
 2 step process
Establish if patient drinks
Administer AUDIT-C to drinkers
BV build CLINICAL REMINDER
Disseminated nationally can we find out how ?
AUDIT-C in MHA used 1.4 million times in 2004

## 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

- 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

- Case Study #1 - Alcohol Screening

**Notes:**
Local clinical informatics expert played key role 
Familiar with errors in MHA AUDIT-C 
Translated: informatics experts & researchers
AUDIT-C in MH package lacked response options for nondrinkers 2 step process
Establish if patient drinks
Administer AUDIT-C to drinkers
B. Volpp built Clinical Reminder
“Diffused” nationally
AUDIT-C in MHA used 1.4 million times in 2004
AUDIT-C added to SHEP Pt. satisfaction survey
Later evaluated  adapted performance measure

THIS IS TOO BUSY

Carol
Knew AUDIT-C was in MHA
Noted errors
Translated between informatics experts and researchers
AUDIT-C in MH package lacking response options for nondrinkers
Only administer only to drinkers
 2 step process
Establish if patient drinks
Administer AUDIT-C to drinkers
BV build CLINICAL REMINDER
Disseminated nationally can we find out how ?
AUDIT-C in MHA used 1.4 million times in 2004

## 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

- 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

- Case Study #1 - Alcohol Screening

**Notes:**
System readiness 
PM: alcohol screening implemented 1990s 
OQP  performance measure 
AUDIT-C had been validated in VA
Sites expected self-scoring clinical reminder
Anticipation of system needs so that HIT tool is available when system is ready
Researchers & clinical leaders collaborating

Presentations to QMIC & PMWG
Colleagues in OMHS: AUDIT-C  MHA
National informatics leaders
Unofficial channels

Collaboration with other innovators essential 
Office of Quality and Performance
Office Mental Health Services 
Informatics experts
System antecedents
MHA in CPRS
PM: alcohol screening implemented (wrong instrument)
System readiness 
OQP  performance measure 
AUDIT-C had been validated in VA
Sites expected self scoring clinical reminder

## 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)

- 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)

- Case Study #1 - Alcohol Screening

**Notes:**
End-users not familiar with AUDIT-C
Problems with “face validity” of validated screening threshold
Lack of “shared meaning” with end-users
Previous focus on “diagnose and refer alcoholics”
New paradigm: counseling patients with unhealthy drinking patterns
Nonstandard assessment of non-drinkers
Lack of quality control
Lack of planning for HIT support before PM announced

Carol
Knew AUDIT-C was in MHA
Noted errors
Translated between informatics experts and researchers
AUDIT-C in MH package lacking response options for nondrinkers
Only administer only to drinkers
 2 step process
Establish if patient drinks
Administer AUDIT-C to drinkers
BV build CLINICAL REMINDER
Disseminated nationally can we find out how ?
AUDIT-C in MHA used 1.4 million times in 2004

Dans Presentation to PMWG 
Dans Linked research to OMHS (AUDIT-C  MHA)
Translates
Collaborates with national informatics leaders
Unofficial channels

## 

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

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

- Case Study #2

## 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

**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

- 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.

**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.

- Case Study #2A – Follow-up Clinical Reminder

## Case Study #2A – Follow-up Clinical Reminder

**Provider Education****:**
**recommended **
**drinking limits**

**Provider Education:**** Components of BI**

## 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

## 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 **

## 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

**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

- Case Study #2A – Follow-up Clinical Reminder

**Notes:**
This is an example where we had the tool, but not system readiness

Of 2,640 eligible patients who screened positive for alcohol misuse, 398 (15%) had any CR use. Sixteen providers (21%) used the CR at least once, with 5 NPs accounting for 73% of first uses.  

## Local Pilot (2003-2005)

**Facilitators**
- Clinical informatics expert
- Identified tools
- Built and reiteratively revised clinical reminder
- Early linkage with local end-users
- 1:1 observation and focus groups key
**Barriers**
- VA providers hard to recruit for focus groups
- Low system readiness

- Case Study #2A – Follow-up Clinical Reminder

## 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 

- “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

- Case Study #2B – Follow-up Clinical Reminder

- Informal Regional Dissemination

**Notes:**
National implementation of AUDIT-C screening 
Demand “from the field” for help with follow-up 
National CR experts asked Carol about follow-up
Shared with 2 sites
Recommended changes
Simplify more
Remove escape option
Move some parts to “Optional section”

After AUDIT-C replaced CAGE as required alcohol screen, lots of questions/confusion
What do we do w/positive screen
We developed FAQ that was posted on OQP website
Still there today – first hit on Google w/AUDIT-C search
Bryan Volpp, who built AUDIT-C screen CR requested our CR so they would have some thing to use
Sent him CR
He made edits to the formatting, sent it back
We agreed to changes – ran same CR here as there
Other sites requested the CR so they would have a tool to fu the positive screens – informal dissemination

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

- % Patients with Positive AUDIT-C whose Provider
- Completed CR for Brief Alcohol Counseling

- Bradley Substance Abuse 2007

- Case Study #2B – Follow-up Clinical ReminderInformal Regional** **Dissemination

**Notes:**
No info on quality of BI 

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

- % Patients with Positive AUDIT-C whose Provider
- Completed CR for Brief Alcohol Counseling

- Case Study #2B – Follow-up Clinical ReminderInformal Regional** **Dissemination

**Notes:**
No info on quality of BI 

## 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

*CIE=clinical informatics expert    

- 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
- *CIE=clinical informatics expert

- Case Study #2B – Follow-up Clinical ReminderInformal Regional** **Dissemination

**Notes:**
After AUDIT-C replaced CAGE as required alcohol screen, lots of questions/confusion
What do we do w/positive screen
We developed FAQ that was posted on OQP website
Still there today – first hit on Google w/AUDIT-C search
Bryan Volpp, who built AUDIT-C screen CR requested our CR so they would have some thing to use
Sent him CR
He made edits to the formatting, sent it back
We agreed to changes – ran same CR here as there
Other sites requested the CR so they would have a tool to fu the positive screens – informal 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

- 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

- Case Study #2B – Follow-up Clinical ReminderInformal Regional** **Dissemination

**Notes:**
Facilitators of Clinical reminder Implementation

This is an example of having the tool and signs of some system readiness on a local level

## 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

- 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

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

**Notes:**
Barriers to Effective 
Brief Alcohol Counseling

## 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 

- 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

- Case Study #2C – Follow-up Clinical ReminderNational Dissemination

**Notes:**
After AUDIT-C replaced CAGE as required alcohol screen, lots of questions/confusion
What do we do w/positive screen
We developed FAQ that was posted on OQP website
Still there today – first hit on Google w/AUDIT-C search
Bryan Volpp, who built AUDIT-C screen CR requested our CR so they would have some thing to use
Sent him CR
He made edits to the formatting, sent it back
We agreed to changes – ran same CR here as there
Other sites requested the CR so they would have a tool to fu the positive screens – informal dissemination

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

**Rates of Documented Brief Alcohol Counseling**

| Baseline Year | PM 
Announced |
| --- | --- |
|  |  Q4FY07 |
| (N 3547) | (N1138) |
|  |  |
| 9% | 9% |

*** **Among Patients with AUDIT-C _>_ 5; p’s < 0.001

- Case Study #2C – Follow-up Clinical ReminderNational Dissemination

**Notes:**
P for feedback being confirmedAdvice	30	30	30	39*	53*
Feedback	26	23	28	35*	48*

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

**Rates of Documented Brief Alcohol Counseling**

| Baseline Year | PM 
Announced | Active 
Performance Measure |  |  |
| --- | --- | --- | --- | --- |
|  | Q4FY07 | Qtr 1 |  |  |
| (N 3547) | (N1138) | (N 536) |  |  |
|  |  |  |  |  |
| 9% | 9% | 9% |  |  |

*** **Among Patients with AUDIT-C _>_ 5; p’s < 0.001

- Case Study #2C – Follow-up Clinical ReminderNational Dissemination

**Notes:**
P for feedback being confirmedAdvice	30	30	30	39*	53*
Feedback	26	23	28	35*	48*

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

**Rates of Documented Brief Alcohol Counseling**

| Baseline Year | PM 
Announced | FY 2008 Active 
Performance Measure |  |  |
| --- | --- | --- | --- | --- |
|  | Q4FY07 | Qtr 1 | Qtr 2 |  |
| (N 3547) | (N1138) | (N 536) | (N 977) |  |
|  |  |  |  |  |
| 9% | 9% | 9% | 19%* |  |

*** **Among Patients with AUDIT-C _>_ 5; p’s < 0.001

- Case Study #2C – Follow-up Clinical ReminderNational Dissemination

**Notes:**
P for feedback being confirmedAdvice	30	30	30	39*	53*
Feedback	26	23	28	35*	48*

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

**Rates of Documented Brief Alcohol Counseling**

| Baseline Year | PM 
Announced | Active 
Performance Measure |  |  |
| --- | --- | --- | --- | --- |
|  | Q4FY07 | Qtr 1 | Qtr 2 | Qtr 3 |
| (N 3547) | (N1138) | (N 536) | (N 977) | (N 969) |
|  |  |  |  |  |
| 9% | 9% | 9% | 19%* | 37%* |

*** **Among Patients with AUDIT-C _>_ 5; p’s < 0.001

- Case Study #2C – Follow-up Clinical ReminderNational Dissemination

**Notes:**
P for feedback being confirmedAdvice	30	30	30	39*	53*
Feedback	26	23	28	35*	48*

## 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 Yano’s 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

**Notes:**
This is an example of the combination of system readiness and the informatics tool be available.
Part of the reason for success is that we built the tool in ANTICIPATION of system readiness.

## 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*

## Conclusions

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

**Notes:**
This is an example of the combination of system readiness and the informatics tool be available.
Part of the reason for success is that we built the tool in ANTICIPATION of system readiness.

## 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

**Notes:**
System antecedents
Infrastructure: CPRS with clinical reminders 
Culture of performance monitoring
Screening for alcohol use disorders - 1990s
System readiness
Patients report need: Large Health Study
Primary care-mental health integration
Performance measure for screening and follow-up 
CPRS expert/primary care clinician
Co-investigator, although not reseacher
Builds clinical reminders 
Translates: researchers and HIT experts
Networks with national HIT experts
Monitors new tools and potential data sources

## Original CR Tried to Replicate Elements in Trials

**Original CR Tried to Replicate Elements in Trials**

- Case Study #2A – Follow-up Clinical Reminder

**Notes:**
Mention getting on agenda as key
Help text = provier education
Extensive assessment

Decisio support
Key = how to make this self sustaining
Separate visits not an option
So VA had implemented routine screening with the AUDIT-C 
We developed a clinical reminder for BI triggered by positive AUDIT-C 

## 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”

**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”

- Case Study #2A – Follow-up Clinical Reminder