# Presentation: 385707

##    Identifying Patients at Risk          of Suicide/Self-harm:   A Demonstration of Clinical        Reminder Patient Lists

- Carol Achtmeyer MN, ARNP
- VA SUD Quality Enhancement Research Initiative
- VA Puget Sound Health Services Research & Development
- _[carol.achtmeyer@va.gov](mailto:carol.achtmeyer@va.gov)_

## Overview

- VistA files and CPRS
- Approach to use of Clinical Reminder (CR) patient lists
- Review example of risk of suicide/self harm
- Strengths and limitations
- Implications for research
- Other query tools in VistA

## CPRS GUI and VistA

- CPRS GUI

- Use of CPRS GUI generates data that is sent to and stored in VistA files.  In turn the data in these VistA files is displayed in CPRS

- Health Factors

- Notes

- Meds

- Labs

- MHA

## CPRS interface displays and generates data stored in multiple VistA files

- Notes (TIU) files

- Mental Health Assistant (MHA) files

- Health Factor files

- CPRS tabs

## Creating a Patient Cohort in VistA

- National tools: No widely accessible tool available to extract nationwide data from VistA
- Local tools:
- Clinical Reminder Patient Lists
- Fileman
- Clinical Reminder Reports

## CR Patient Lists: Overview

- Introduced in 2006, but evolving in its use and capability
- Uses the tools of clinical reminders software to build a cohort of patients meeting a defined criteria
- Once list is built, can be auto-tasked or manually run at repeated intervals

## CR Patient Lists: General Info

- Faster than other options (CR reports or Fileman queries)
- Can be used to extract certain data elements as well
- Demographic Data – readily available, does not need to be programmed
- Clinical data – program “insert data” command
- Data can be updated on an existing list at any time
- Output file is ASCII text with delimiters
- Transfer to Excel, Access, Stata etc.
- Built by Clinical Applications Coordinator (CAC) or Clinical Reminders person

## CR Patient Lists: Potential Uses

- Care Managers: track a group of patients on a monthly basis
- Quality Managers: run a list to see which patients meet certain performance measures
- Researchers:
- Define a list of patients to determine what charts to review manually
- Potential for use for data extraction as CPRS Patient List functionality evolves

## Types of data in VistA to Create a CR Patient List   (9/08)

- Lab Tests
- Health Factors
- Mental Health Assistant (MHA) test results
- Hospital/Clinic Location
- Progress Note Titles
- Medications
- ICD9/CPT codes
- Immunizations
- Radiology procedures
- Computer Findings used by clinical reminders
- Tb test results
- Vital Signs

- Data displays

- Limited or no display

- Unknown

- All items can be used to define list, but not all available to display data

## Approach to Use of Patient Lists

- Identify characteristics of the cohort
- How are these characteristics represented in your system?
- What information do you want to display in the report?
- Must be computable data
- Who is the person in your system that will build and run this report?
- Data and security

## Patient Lists and Mental Health Assistant (MHA) tests

- MHA includes alcohol, depression and PTSD screening
- More MHA tests added in January 2008
- Multiple validated mental health screens
- Can be accessed in CPRS
- Using this new feature, a patient list may be based on:
- Total score of a MHA screen
- Response to an individual MHA screen question

## CR Patient Lists: MHA Findings to Identifying Suicide Risk

- A PHQ9 depression screen is required if initial PHQ2 screen is positive (Performance Measure)
- PHQ9 Question #9 asks about thoughts of self harm
- How can we monitor that patients who have reported thoughts of self harm on the PHQ9 have had a suicide assessment?
-              Answer: Patient Lists!

## CR Patient Lists: MHA Findings to Identifying Suicide Risk

- Example of how patient sample is defined (cohort definition)
- Patients with thoughts of self harm *as reported on the PHQ9*
**  ****AND**
- No documentation of suicide assessment

## 
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

- 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

**PHQ9: Question #9**

- CR Patient Lists: MHA Findings to Identifying Suicide Risk

## CR Patient Lists: MHA Findings to Identifying Suicide Risk

- Screen Capture of the PHQ9 in CPRS. Question 9 is highlighted

## CR Patient Lists: MHA Findings to Identifying Suicide Risk

- Screen Capture of PHQ9 text in a progress note.  Note text generated by Depression Follow Up Clinical Reminder

## Target list is: patients who have reported thoughts of self harm on PHQ9, but still need a suicide risk assessment
In the Sample Definition: Patients with documentation of suicide risk assessment are excluded
How do we know if a patient had a suicide risk assessment or not?
i.e.  what computable data is available that I can use to represent the concept of suicide risk assessment?

- In the Sample Definition: Patients with documentation of suicide risk assessment are _excluded_
- How do we know if a patient had a suicide risk assessment or not?
- i.e.  what computable data is available that I can use to represent the concept of suicide risk assessment?

- CR Patient Lists: MHA Findings to Identifying Suicide Risk

## Review of clinic process to assess suicide risk showed two things we could use for the patient list query:
Health Factors: linked to suicide risk assessment in depression/PTSD follow-up CR’s
A Progress Note Title: “Mental Health Triage Evaluation Note” used by MH staff included a suicide risk assessment template

**Health Factors:** linked to suicide risk assessment in depression/PTSD follow-up CR’s
**A Progress Note Title**: “Mental Health Triage Evaluation Note” used by MH staff included a suicide risk assessment template

- CR Patient Lists: MHA Findings to Identifying Suicide Risk

## Health Factor: Suicide Risk Assessment Completed

- When this choice is checked, a data tag called a Health Factor is sent to VistA
- This health factor can be used to show that a suicide risk assessment was done

## Patient Sample and Report

- Sample definition:
- Patients who have reported thoughts of self harm but have not had suicide assessment
- List of information to display for each patient on this list:
- Name, telephone number and SSN
- PHQ 9 total score (MHA PHQ9)
- PHQ 9 question 9 response (MHA PHQ9)
- Alcohol use screen score (MHA AUDC)

## Demographic Data Available in CPRS CR Patient Lists (9/08)

|  CURRENT ADDRESS
 PHONE NUMBER
 APPOINTMENT DATE
 CLINIC
 SSN
 DATE OF BIRTH
 AGE
 SEX
 DATE OF DEATH
 REMARKS
 HISTORIC RACE
 RELIGION
 |  MARITAL STATUS
 ETHNICITY
 RACE
 PRIMARY ELGIBILITY CODE
 PERIOD OF SERVICE
 SERVICE CONNECTED
 VETERAN
 TYPE
 ELIGIBILITY STATUS
 CURRENT MEANS TEST
 |
| --- | --- |

## CPRS CR Patient Lists: Sequence

- Operation: **REMOVE**
- List Rule: SUICIDE ASSESS FINDINGS (FR)
- Rule Type: FINDING RULE
- Reminder Term: SUICIDE ASSESS (RT)

- Sequence: 5
- Operation: **ADD PATIENT**
- List Rule: PHQ9 Q9 (FR)
- Rule Type: FINDING RULE
- Reminder Term: PHQ9 Q9 POS (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)

- Example of the sequence used in clinical reminders patient list software

## Patient List results: ASCII Text

- Patient Demographic Report*
- PATIENT^PHONE NUMBER^SSN^AUDIT-C SCORES,"FINDING NAME"^AUDIT-C SCORES,
- "VALUE"^PHQ9 SCORES,"FINDING NAME"^PHQ9 SCORES,"VALUE"^PHQ9
- SCORES,"R",9^\\
- PATIENT,ONE^(111)111-1111^000-00-1234^AUDC^11^PHQ9^21^Nearly every day^\\
- PATIENT,TWO^(111)111-1112^000-00-1235^AUDC^7^PHQ9^17^Several days^\\
- PATIENT,THREE^(111)111-1113^000-00-1236^AUDC^1^PHQ9^22^Several days^\\
- PATIENT,FOUR^(111)111-1114^000-00-1233^AUDC^6^PHQ9^12^More than half the days^\\
- * Data is fictitious

**The results display as ASCII text with delimiters. This text  is copied and saved into a notepad file **

- Creating Excel Table from ASCII text

- PATIENT^PHONE NUMBER^SSN^AUDIT-C SCORES,"FINDING NAME"^AUDIT-C SCORES,
- "VALUE"^PHQ9 SCORES,"FINDING NAME"^PHQ9 SCORES,"VALUE"^PHQ9 SCORES,"R",9^\\
- PATIENT,ONE^(111)111-1111^000-00-1234^AUDC^11^PHQ9^21^Nearly every day^\\
- PATIENT,TWO^(111)111-1112^000-00-1235^AUDC^7^PHQ9^17^Several days^\\
- PATIENT,THREE^(111)111-1113^000-00-1236^AUDC^1^PHQ9^22^Several days^\\
- PATIENT,FOUR^(111)111-1114^000-00-6234^AUDC^6^PHQ9^12^More than half the days^\\
- PATIENT,FIVE^(111)111-1115^000-00-1434^^^PHQ9^17^Several days^\\

- ASCII text file

- Excel display (after editing headings)

- Use “Import  External Data” command” in Excel

## CPRS CR Patient Lists: Identifying Suicide Risk

- How might this list be used?
- Facilitates timely follow up of patients who need suicide risk assessment
- Additional information of
- level of depression (PHQ9 score),
- frequency of suicidal thoughts (Q9 PHQ9)
- possible heavy alcohol use (AUDIT-C score)
- allows triage of the list to assess pts who may need urgent evaluation
- Can re-run list regularly – follow if patients are getting assessed.  If clinic processes changed, can use list to determine if change successful

## CR Patient Lists:Process Issues

- 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?
- Data management expertise?
- How will data be stored securely?

## CR Patient Lists:Technical Issues

- Not all CR finding items can be used to display data, must be “csub” findings
- MH test dates not yet available in data display
- A Clinical Applications Coordinator (CAC) will need to be involved on an ongoing basis.
- Patient Lists generated from CR reports can also display data – requires some additional steps

## CR Patient List: Limitations

- No date associated with many of the findings, so can only get data in a certain time range
- Can only display the most recent finding for a patient, not multiple findings
- Due to technical issues, not all data fields in a particular file may be available to insert in to a report

## Can CR Patient Lists generate data for a research data base?

- Patient list tools useful for generating a list of patients meeting criteria defined by the available fields.
- Could identify patients for manual chart review
- But, as of today, with the limitations of Clinical Reminders patient lists, it is probably not ready to pull data for research data base purposes

## Uses of CR Patient Lists

- For research: Consider using patient lists to define or follow a sample.
- For care managers/QI: excellent tool to quickly identify a group, follow patient cohort, or give “snapshot” of clinical data

## CR Patient lists: Changes (? release date)

- Dates will be added to MHA tests and other clinical findings
- Will include tools that allow the exchange of patient list queries or components between facilities
- Additional csub data will be available

## Other Tools to query VistA: Fileman

- Pros:
- Creates lists of patients
- Flexible, allows complex queries
- Reports can include clinical data
- Cons
- Steep learning curve
- Must be familiar with VistA file structure
- Comparatively slow

## Other tools to Query VistA: Clinical Reminder Reports

- Pros
- Able to identify a cohort
- Able to apply complex logic to define the cohort
- Used for QI purposes
- Cons
- Must convert “due” and “applicable” to numerator and denominator
- Faster than fileman, but patient lists are faster than CR reports
- Does not display clinical data

## Summary

- CR Patient list functionality can be used to create patient cohorts that can be followed over time, as well as display data.
- There are some limitations to this tool that may limit its use for researchers, but there may be multiple applications for care managers and QI staff.
- Fileman and clinical reminder reports are also available, but patient list may be preferable due to it’s speed, function and usability

## Resources

- General Patient List Training:
- _[VEHU 2006: Class 309h Playing by the Rules](http://www.vehu.va.gov/vehu/vehu2006/ppt/309H_ClincialRemindersPatientListsPlayingByTheRules.ppt)_
- Details of building Risk of Suicide list discussed here
- _[http://www.vehu.va.gov/vehu2008/ppt/9915_LL.ppt](http://www.vehu.va.gov/vehu2008/ppt/9915_LL.ppt)_
- Cyber series 2007: Clinical Reminders & Pt Lists
- _[http://vaww.virec.research.va.gov/EducationResources/Seminars/Informatics032007ra.ppt#267,20,Reminder Reports vs. Patient Lists](http://vaww.virec.research.va.gov/EducationResources/Seminars/Informatics032007ra.ppt#CR Patient Lists: General Info)_