# Presentation: 616094

## NetDSSFacilitating Implementation of aDepression Care Management Intervention Using Web-Based Decision Support

- John Fortney, PhD
- June 17, 2008
- South Central MIRECC
- HSR&D Center for Mental Health and Outcomes Research
- HSR&D Mental Health QUERI
*Central Arkansas Veterans Healthcare System*

## Funding Sources

- VA IIR 00-078-3
- VA IMV 04-360
- VA MNT 05-152
- NIMH R01 MH076908-01

## Clinical Background

- 75% of patients treated for depression receive care in primary care settings
- 20-50% of primary care patients stop taking medications in the first month of treatment
- 30-50% of primary care patients don’t respond to the initial medication
- 15-30% of primary care patients treated for depression receive guideline concordant care.

## Components of Collaborative Care

- Use of informatics to track critical processes
- Use of clinical practice guidelines
- Stepped care model
- Ready access to mental health specialists
- Delegation of key provider functions to non-physician members of a practice team
- Care Management

## Depression Care Management

- Education and activation
- Barrier assessment and resolution
- Comorbidity assessment
- Depression symptom monitoring
- Suicide risk assessment
- Medication adherence monitoring
- Side-effects monitoring
- Self Management goal setting and monitoring

## Telemedicine-Based Collaborative Care for CBOCs

- Offsite depression care team
- Nurse care manager
- Pharmacist
- Psychiatrist
- Telephones
- Care manager encounters with patients at home
- Interactive Video
- Psychiatric evaluations with patients at CBOC
- Electronic Medical Records (CPRS)
- Communication among on-site PCPs and offsite depression care team

## Slide 7

## Effectiveness of TEAM Intervention

- TEAM Study1,2 – Randomized effectiveness trial of telemedicine-based collaborative care in rural CBOCs
- Increased medication adherence
- Increased rates of response and remission
- Increased health status
- Increased patient satisfaction
- Fortney JC**, **Pyne JM, Edlund MJ, Robinson DE, Mittal D, Henderson KL.  Design and Implementation of the Telemedicine-Enhanced Antidepressant Management Study. * General Hospital Psychiatry, 28(1): 18-26, 2006*
- Fortney JC**, **Pyne JM, Edlund MJ, Robinson DE, Mittal D, Henderson KL. A Randomized Trial of Telemedicine-Based Collaborative Care for Depression, *Journal of General Internal Medicine,* in press.

## Medication Adherence Casemix-Adjusted Results

**OR=2.1p=0.04**

**OR=2.7p<0.01**

## Response  Casemix-Adjusted Results

**OR=1.9p=0.02**

**OR=1.4p=0.18**

## RemissionCase-mix Adjusted Results

**OR=1.8p=0.14**

**OR=2.4p=0.02**

## Mental Health Component (MCS) Casemix-Adjusted Results

**P=0.07**

**P<0.01**

## Satisfaction Casemix-Adjusted Results

**OR=1.8p=0.01**

**OR=1.7p=0.03**

## Implementation Research

- Partners In Care study
- Fidelity to the care manger protocol was lower than anticipated
- Computerized tracking system was recommended as a result1.
- RIPPLE Study
- Implement telemedicine-based collaborative care in contract CBOCs.
- Decision Support System was needed to maintain _fidelity_ to the evidence base during implementation?
- Rubenstein LV, Jackson-Triche M, Unutzer J, Miranda J, Minnium K, Pearson M, Wells K. Evidence-Based Care for Depression in Managed Primary Care Practices, Health Affairs, 18(5): 89-105, 1999.

## Design and Development of NetDSS

## Cross-functional Design Team 

- Bill Raney, RN – Depression Care Manager
- Amanda Davis MA – Technical Writer
- Chris Steven – Web programmer
- Silas Williams – Web programmer
- Richard Hedrick – Systems Analyst
- Jeff Pyne, MD – Psychiatrist
- John Fortney, PhD – Translator

## Scope

- Users – Care Managers
- Patients – PC patients with depression
- Timing – Between PC visits
- Purpose
- Panel management
- Trial management
- Structured assessment
- Decision support
- Workload and Outcomes Reports

## Attributes

- NetDCMS was designed to have most of the required features of a clinical information system as outlined in a recent article by Kilbourne and colleagues (2006) including:
- Short training time, with uncluttered screens that are easy to navigate
- Web-based
- Use of drop menus and logic checks
- Compliant with HIPAA standards and conforms to standards to internet security/encryption
- Use of clinic reminders
- Capability of creating individual care plans with self-management information and disease severity rating
- Capacity to print out summary data on quality and other patient outcomes
- Linked with, but not a substitute for electronic medical records
- Supports multiple chronic illnesses
- Kilbourne AM, McGinnis GF, Belnap BH, Klinkman M, Thomas M. The role of clinical information technology in depression care management. *Adm Policy Ment Health*. 2006 Jan;33(1):54-64.

## Features

- NetDSS has the following functional capabilities:
- patient registry and panel management
- trial and phase management
- encounter scheduler
- decision support
- progress note generator
- workload report generator
- NetDSS guides the care manager through a **self-documenting** and **evidence-based** patient encounter using scripts and self-scoring instruments which support:
- patient education and activation
- barrier assessment
- comorbidity assessment
- depression severity monitoring
- suicide risk assessment
- adherence monitoring
- side-effect monitoring
- self-management activities

## Story Board

## Assembling the Components

## Decisions

- CPRS vs. stand-alone application
- Target VA vs. private sector vs. both
- Web-based vs. CD-ROM
- Flexible vs. structured
- User friendly vs. efficient

## Development Process

- Rapid prototype-test-prototype product development cycles
- Monthly planning meetings
- Programming
- User testing
- Revisions & additions
- Continuous beta test version (2 years)
- Users Guide & Training Manual
- Version 1.x with biannual updates (1.5 years)

## Current Users

- VA RIPPLE Study (Contract CBOCs)
- Little Rock, AR
- Loma Linda, CA
- Los Angeles, CA
- VA HiTIDES Study (VA Medical Centers)
- Little Rock, AR
- Houston, TX
- Atlanta, GA
- NIMH OUTREACH Study (Federally Qualified Health Centers)
- Little Rock, AR
- Pine Bluff, AR
- West Memphis, AR
- Lepanto, AR
- Corning, AR
- Pochahontas, AR
- Huntsville, AR
- PC/MH Integration Initiative
- Little Rock, AR
- New Orleans, LA

## Web-Sites

- Non-VA Version URL
- _[https://www.netdss.net/](https://www.netdss.net/)_
- VA Version URL
- Send request from VA.gov email to:
- _[virec@va.gov](mailto:virec@va.gov)_
- _[John.Fortney@VA.gov](mailto:John.Fortney@VA.gov)_

## NetDSS Demonstration