NetDSSFacilitating Implementation of aDepression 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

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

RemissionCase-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

Database 

Care manager [ clinic [ provider [ patient ] ] ]

Trial types [ phases [ success/failure ] ]

Instrument scoring 

Outcomes tracking

Automated Treatment Recommendations

Registry

Encounter

Scheduler

Assessments

 Workload Report

Progress Notes

Decision Support

Assembling the Components

Story Board

Database Structure

User Interface

Evidence-Based Protocols

Trial Management

Instruments and Scripts

Panel Management

Decision Support

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/
        - VA Version URL
        - Send request from VA.gov email to:

virec@va.gov

John.Fortney@VA.gov

NetDSS Demonstration