MHA OverviewVIREC Cyberseminar

Kathleen Lysell, PsyD

Rick Owen, MD

November 20, 2007

Session Objectives
        - Be familiar with the VHA Mental Health Assistant software, including its use and applications in clinical care;
        - Understand how the software could be used in a research setting;
        - Understand the process for creation of national database of MHA assessment data; and
        - Know about how the implementation of the software was evaluated

Mental Health Assistant Software

Mental Health Assistant	
        - Graphical User Interface (GUI) for the Mental Health testing package.
        - Originally released 2002
        - Provides secure computer environment for patient administered testing
        - Only VistA application currently available that stores survey/self report information as data
        - 2,800,000 assessments using MHA instruments completed in FY07

Instruments Currently Available in MHA
| AIMS  | BSI18 | MCMI2 | SCL9R |
|-------|-------|-------|-------|
| ATQ   | BUSS  | MCMI3 | SDES  |
| AUDC  | CAGE  | MISS  | SF36  |
| AUDIT | CESD  | MMP2S | SMAST |
| AUIR  | CESD5 | MMPI2 | STAI  |
| BAI   | DOM80 | PCLC  | VALD  |
| BDI2  | DOMG  | PCLM  | WAS   |
| BHS   | HLOC  | PHQ9  | ZUNG  |
| BPRS  | IEQ   | RLOC  |
| BSI   | MBMD  | SAI   |

MHA3 New Features—Patch YS*5.01*85
        - MHA files completely restructured in VistA
        - Launch from CPRS Tools Menu
        - Pass progress note to CPRS
        - New Instruments for MH Screening, nursing, TBI
        - With clinical reminders patch 6, all MHA instruments will work with reminders
        - Reminders will be able to use MH scales and individual responses in finding logic

Current System MH Test Files
| FILE # | Name (Legacy)                 |
|--------|-------------------------------|
| 601    | MH INSTRUMENT                 |
| 601.2  | PSYCH INSTRUMENT PATIENT      |
| 601.3  | COPYRIGHT HOLDER              |
| 601.4  | INCOMPLETE PSYCH TEST PATIENT |
| 601.6  | MH MULTIPLE SCORING           |

MH Files New with Patch YS*5.01*85
| 601.71  | MH TESTS AND SURVEYS  |
|---------|-----------------------|
| 601.72  | MH QUESTIONS          |
| 601.73  | MH INTRODUCTIONS      |
| 601.74I | MH RESPONSE TYPES     |
| 601.75I | MH CHOICES            |
| 601.751 | MH CHOICETYPES        |
| 601.76  | MH INSTRUMENT CONTENT |
| 601.77I | MH BATTERIES          |
| 601.78  | MH BATTERY CONTENTS   |
| 601.781 | MH BATTERY USERS      |
| 601.79  | MH SKIPPED QUESTIONS  |
| 601.81  | MH SECTIONS          |
|---------|----------------------|
| 601.82  | MH RULES             |
| 601.83  | MH INSTRUMENTRULES   |
| 601.84  | MH ADMINISTRATIONS   |
| 601.85  | MH ANSWERS           |
| 601.86I | MH SCALEGROUPS       |
| 601.87I | MH SCALES            |
| 601.88  | MH DISPLAY           |
| 601.89  | MH CHOICEIDENTIFIERS |
| 601.91  | MH SCORING KEYS      |
| 601.92  | MH RESULTS           |
| 601.93  | MH REPORT            |

What does file structure mean?
        - Old structure, results only stored as response string TTFT, report recalculated on the fly every time test accessed
        - Very difficult to research test results on long tests
        - All tests had to be coded into system using mumps

New File Structure	
        - Series of connected files that store entire test administration data
        - Can evaluate scales, questions, raw or transformed scores rather than just response strings
        - Greatly facilitates addition of new test content—create instrument using Delphi tool that translates it to mumps file structure
        - HL7 messaging used to create national testing database

New Instruments Added in MHA3
        - BOMC (Blessed Orientation Memory Concentration) Test
        - Braden Skin Risk Assessment
        - Morse Falls Risk Scale
        - PHQ-2
        - PC-PTSD
        - TBI 2nd Level Evaluation

Modified Instruments in MHA3
        - AUD-C:  Invoke Skip Logic; add option “Never” as response to Item 1 and “0” as response to Item 2
        - PHQ-9:  Add 10th question regarding impact of symptoms on overall functioning

PHQ-9 Test Form in MHA3

MHA Research Example—AUDIT-C

AUDIT-C response strings from alcohol use screens were extracted from VistA at a VA facility     (n=65,484 AUDC response strings) for a 2 year period.

90 combinations were identified for all AUDIT-C scores.  11 response strings were identified that equal  a score of 4 (see chart). 

The most common drinking pattern representing a score of 4 was 400 (n= 11387, 17% of all combinations) - drinking 1-2 drinks daily, but never drinking > 6 drinks per occasion (binge drinking).  The “400” response string accounted for 83% of all scores equaling 4.

There were 1249 (1.9% of all combinations) occurrences where the score was 4 and the response string indicated binge drinking, as represented by any response string with a 3rd digit of 1 or more (e.g. 211,301,112). This pattern accounted for 9% of all scores equaling 4.

AUD-C Response String Frequency

AUDIT-C Response Samples

Item checked equals 2 points

Item checked equals 1 point

Item checked equals 1 point

Enhancements in Clinical Reminders	
        - Clinical Reminders updated it’s code with patch PXRM*2.0*6, to work with new MH files
        - Can work with MH scale within an instrument, or specific item within an instrument as reminder finding

Reminders Using MH Item Response
        - FINDING ITEM: AUDC//
        - MH SCALE: 276//default of scales associated with the instrument
        - CONDITION: I V("R",1)="Four or more times a week“ if the value of response to Item 1 is “four or more times a week”

AUD-C Response String in Reminder Logic
        - Condition: I V("R",1)=“Four or more times a week”
        - Condition: I V("R",2)="3 or 4" 
        - Condition: I V("R",3)="Never" 
        -  Function String: FI(2)&FI(3)&FI(4)

      Expanded Function String:

       FI(AUDC,R,1)&FI(AUDC,R,2)&FI(AUDC,R,3)

	  Found Text: Patient who might drink less than the safe limits.

Using Reminders with MH Instruments
        - Identify population, desired frequency of measurement 
        - MH Performance Measures, FY08
        - PHQ-9, AUD-C, PC-PTSD
        - PC MH Integration Assessment
        - PHQ-9, BAI, PCL, AUD-C

Testing Database	
        - MH testing data stored in local VistA files
        - MHA3 enhancements also create national testing database
        - Test administrations transmitted using HL7 messaging
        - Physically located in Pittsburgh, MH Informatics section
        - Only includes test administration data, only data generated after MHA3 patch is installed in local system
        - Establishing protocols for data usage with Austin Corporate Data Warehouse

Project Review, Lessons Learned

Business Case
        - MHA is a national software package; the mental health package was one of the early clinical packages in VistA
        - Significant cost savings/benefit identified in automating psychological testing process
        - Improved clinical processes demonstrated

Expanding Presence
        - Software historically limited to MH usage, but functionality valuable in other clinical settings
        - Identified as tool that will store self report information as data rather than text
        - Useful in decision support
        - Easy to add content in environment where new development is difficult to fund
        - Interact with clinical areas that have specific assessment by self report needs to broaden investment
        - Integrate with CPRS
        - Provide tools requested by program offices

Approval Process
        - Submit Project Requests to HISEB
        - HISEB prioritizes all requests in portfolio
        - IDMC reviews priorities of 5 HISEB’s
        - Funding based on budget from Congress
        - Executive priorities funded off the top
        - Multi-year projects that are approved receive funding priority in subsequent years

Issues
        - Sites do not utilize full capacity of package
        - Perception that it is only for psychological testing
        - Adequate resources to have computers and space to use for patient administration
        - Extended period of significant restriction of development resources
        - Uncertainty around VA software development strategies

Next Steps

Clinical Content	
        - Immediate goal
        - Suicide prevention, TBI follow-up evaluation—high visibility, high priority items
        - Behavioral health—pain
        - Mental health—recovery oriented assessment tools
        - Geriatrics, HBPC assessment tools

Authoring Tool
        - Use to build local instruments
        - Delphi application—no programming experience necessary
        - Builds questionnaires with scoring rules and reports templates

VUID
        - Veteran Unique Identifier
        - Link to Enterprise Reference Terminology
        - Using SNOMED to code each item in MH tests
        - Provide Standardized coding/terminology associated with elements of assessments

References
        - Graham, A., et al. (2007). Effect of using different modes to administer the AUDIT-C on identification of hazardous drinking and acquiescence to trial participation among injured patients.  Alcohol and Alcoholism, 42, 423-429
        - Bush, K., et al. (1998). The AUDIT Alcohol Consumption Questions (AUDIT-C) An Effective Brief Screening Test for Problem Drinking.  Archives of Internal Medicine, 158, 1789-1795.
        - Achtmeyer, C et al (2007). Using Mental Health Assistant AUDIT-C Data to Describe Patterns of Alcohol Use.  VeHU Conference, Orlando, FL.  http://vaww.vehu.med.va.gov/vehu/vehu2007/ppt/9903_LL.ppt