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

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

VistA Files

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 

Notes (TIU) files

Mental Health Assistant (MHA) files

Health Factor files

CPRS interface displays and generates data stored in multiple VistA 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

CR Patient Lists: MHA Findings to Identifying Suicide Risk

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

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

CR Patient Lists: MHA Findings to Identifying Suicide Risk
        - 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?

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 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 |
|-----------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------|

Sequence: 10           

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)

CPRS CR Patient Lists: Sequence

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
        - Details of building Risk of Suicide list discussed here
        - 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