COMMEND

Collaborative Mental Health Manage

Enhanced Dashboard

Integrating Measurement Based Care int

Mental Health Workflow Workflow with COMM

COMM

Steven E. Li ndl ey, MD, PhD D Y W PhD Dan Y. Wang, PhD

lindleys@stanford.edu Dan.Wang@va.gov
Question?

• What category best describes your int

this talk?

– Clinical/Research/Administration

• Are you a mental health clinician and/

researcher?

– Yes/No
OUTLINE

• 1. Barriers to measurement based care in me

health

• 2. D i es gn f t ea ures in the coll ba orative ment 

a 

management enhanced dashboard (COMME

• 3. Lessons learned from iterative design depl• 4. Directions for future development
–

Measurement‐based Care

in Mental Health

• Systematically collecting and recordin

– treatment interventions– outcomes– side effects

using data to inform treatment treatment decisions decisions

• ...essential to excellent mental health 

Harding, J Clin Psychiatry 2011
Measurement‐based care aff

individual care

• Prompts change of intervention if nee• Prompts additional interventions/serv• Prompts step‐down in care after funct

has improved

• Orients providers/programs toward o

• Increases it t n erest in evidence‐b d ase c
–

Measurement‐based care aff

management of program

• Prompts more frequent p g ro ram redesig• Prompts more targeted program redesig• Focuses attention on outcomes• Increases interest in evidence‐based care• Enables...

– Performance Performance evaluation evaluation of staff, clinic, and t

t

– Evidence‐based negotiations with leadershi
Improving the Quality of Me

Heal ht Care

Institute Institute of Medicine Medicine 200

• Despite the availability of effective MH

treatments, significant deficiencies ex

US, including including unjustified unjustified variations variations in 

of care provided, safety issues, and sig

deviations deviations from evidence evidence‐based care
VA Mental Health Care Evalua

Rand Corp 2011

• Quality of care for veterans with MH o

is the same or better than in the comm

• Quality of care across facilities varies

• Significant ignificant deviations deviations from evidenced evidenced

practices.
VA Mental Health Care Evalua

Rand Corp 2011

• Suggestions in the report

– ability to create clinical registries– tools that can be accessed in real time with

assistance

– tools that minimize additional data entry, ar

use, and allow high‐level tracking of eviden

care
What are the Barriers? Barriers?

• 2007 VA national expert consensus id

– information overload– inefficient data presentation that does n

th d e nee s of providers

– organizational policies/procedures impe
Other Known Barriers Barriers

– negative impact on workflow

– duplication of work

– l k ac of buy‐in of clinical l d ea ers

– insufficient training

– lack of end‐user involvement

– unresponsiveness to end‐user feedback

– barriers to rapport with patients

– measures not relevant and useful to clinicia

Coombs, 2011; Young et all, 2007; Trivedi et a
,

VA Palo Alto Outpatient MH Pr

Survey

• Providers rated tracking patient outco

very important (M=4.18, SD=0.95) (1=

all to 5=Extremely important)

• But only 53% reported doing so with

standardized measures at least 20‐30% 

time
VA Palo Alto Outpatient MH Pr

Survey

• Reasons for not using stand di ar zed meas

included “entering data into the clinical t

WAY too time consumi ” ng .

• About half of providers (47%) use individ

measures to make treatment decisions.

• Majority ajority (77%) recorded recorded the information information 

session note rather than EMR.
COMMEND Developmen

• 2010‐11 VA Greenfield Innovation Gr

• 2011‐12 VA Office of Mental Health Fu

Fu

• Leveraged knowledge and experience 

of successf l u computeri d ze d i ec sional 

tools for hypertension and opioidmanagement called the Athena Decisi

Support Support Systems Systems developed developed by Dr. Ma

Goldstein and colleagues
Design Features

• Ease of use

• Minimize Minimize additional additional data entry

• Relevant to patient care• Fits within workflow• Clinically Clinically useful data presentation presentation
W bB

Commend Commend Architecture

Physician Computer Physician Computer 

(hundreds per site) 

CPRS Client & GUI 

MDWS 

Commend Server Computer(s) 

Tomcat Server 

MDWS 

Commend Client 

listener 

Tomcat Server 

JDIC 

AppsIDVerify WS Commend JSP 

Commend Client 

WebBrowser 

Commend SQLServer Database 
Synchronized Synchronized with CPRS
Patient List

Can see appoi t n ment I f n ormation and changes in outc
Clinically useful g p ra hs
Patient Detail

Ability to adjust display with a click
Patient Detail

Ability to adjust display with a click
Patient Detail

Easy to access other areas
Patient Detail Three areas for data entry
Patient Detail Click to open therapy mode
Patient Detail Enter up to two treatments
Patient Detail Click to enter standard measure
Patient Detail Enter total score
Patient Detail Option for goal tracking
Patient Detail Select from available options
Patient Detail Option to create own measure
Patient Detail Create and save new measure
Patient Detail Option to enter side effects
Patient Detail Type and frequency
Patient Detail Click to create note
Note Template (Top)
Note Template (Bottom)
Advantages of COMMEND N

Templates

• Automatic reload from previous note 

review and editing

• Template “adapts” to use for a particu

patient patient or type of therapy therapy‐automatica

automatica

opens sections used before
COMMEND Workload Rep
Treatment Intervention Re
Initial Deployment

• PTSD Cli i n cal Team (C) P T

– Psychologist, social workers, and recreation

therapists providing evidence‐based psycho

for PTSD

– Located in three different geographical loca– One 1 1⁄2 hour training session with a team a

observed
Data Collected Collected on Usage

Quantitative Data

– Logging of User Events

– Online Surveys

Qualitative Data– Real‐time comments– Interviews
User Events/Logs

• Able to track

– frequency of use

– which features are

utilized

– types of data entered
Existence of Some Features 

Apparent

• provider who thought patients were m

from her panel unaware of p ga ing but

search features

• provider who thought scores were mi

not know how to adjust displayed out
Workflow Impediments

• Currently COMMEND not designed to m

assessment requirements

• Too cumbersome cumbersome when cross‐covering covering o

brief evaluations

• Need to close the encounter ASAP‐no tim

write a detailed detailed COMMEND COMMEND note
Organizational Impedime

• 

Some

ad ii i m

nistrative requirements hi

n

d

e.g., Mental Health Assistant PCL for OE

PTSD patients patients

, need for telehealth telehealth conse

conse

• 

Currently

a

“patient panel”

s

hows

all pa

seen in

a

6

‐week window not those assig

provider

• COMMEND can only analyze notes save

d

COMMEND
”

Providers Motivations Need t

Altered

• Some providers not motivated to save

treatment interventions

– (paraphrase) “I know how I have been tr

patients. It is no use to me to record the 

mode because the treatment history is w

known to me.”

• Acknowledged information may be useful to 
Useful Features

• E hn anced W kfl or ow

• Automatic display of previous note text for 

• Ability to sort panel by scores allows one 

who needs more attention

• Ability Ability to check which patients patients had miss

miss

appointments and might need reminder

• Being able to see all scores gives a fuller 

of the patient’s state

• Ability Ability to review own workload workload report re

re

past performance or others
Features Requested

(and since added)

• Note backup/draft

• Additional standard assessment scores

• Ability to create variable scale custom go• Ability to have compl t e e management o

goals ‐‐‐add, update, disable

• Enabled selection of note titles with auto

re‐use

• Update of encounter list at time of note‐
Future Directions

Modifications of COMMEND to facilitate use

• Time saving features features in note template template

• Quick Note: allow a quick save of basic

information to close encounter and edit later

• Integrate entry of therapy mode and outcomes

into note template

• Easier access of actionable items

•Display outcome changes as red‐green‐yellow

indicators in patient panel

Modification of Workflow to facilitate use

• “E‐Clinic”‐select group of earlier earlier adopters adopters dedicated dedicated to

the use of new tools/modes of care delivery
Future Directions

• Mental Health Clinical Registry
Design Team

• Steven Lindley, MD/PhD Director Outpatient M

VAPAHCS

• Dan Y. Wang, Ph.D., Software Software Architect Architect (Athena

(Athena

Medcisive LLC

• Justin G. Chambers Chambers, Senior Software Software Engineer Engineer, 

LLC

• Joe Ruzek, Ph.D, D&T, NCPTSD

• Eve Carlson, PhD, NCPTSD

• Sara Landes, Landes, PhD, NCPTSD

• Noah DeGaetano, MD, Trauma Recovery Progr

VAPAHCS