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					                       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
 Delegationof 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

    1.     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
    2.     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
              90          OR=2.1           OR=2.7
              85          p=0.04           p<0.01

              80
              75
Probability




              70                                    Usual Care
                                                    Intervention
              65
              60
              55
              50
                    Six Months     Twelve Months
                         Response
                   Casemix-Adjusted Results
              50                           OR=1.4
              45                           p=0.18

              40          OR=1.9
              35          p=0.02

              30
Probability




              25                                    Usual Care
              20                                    Intervention
              15
              10
              5
              0
                    Six Months     Twelve Months
                          Remission
                   Case-mix Adjusted Results
              50
              45
              40                           OR=2.4
              35                           p=0.02

              30
Probability




                           OR=1.8
              25           p=0.14                   Usual Care
              20                                    Intervention
              15
              10
              5
              0
                     Six Months     Twelve Months
    Mental Health Component (MCS)
      Casemix-Adjusted Results
                15

                                           P<0.01


                10
Change in MCS




                           P=0.07

                                                    Usual Care
                                                    Intevention
                5




                0
                     Six Months     Twelve Months
                         Satisfaction
                    Casemix-Adjusted Results
              100

              90           OR=1.8           OR=1.7
                           p=0.01           p=0.03
              80
Probability




              70
                                                     Usual Care
              60                                     Intervention
              50

              40

              30
                     Six Months     Twelve Months
          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?

    1.     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
 BillRaney, 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

    1.   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

 Registry                                                          Workload
                                                                   Report

                             Database
              Care manager [ clinic [ provider [ patient ] ] ]
 Encounter    Trial types [ phases [ success/failure ] ]            Decision
 Scheduler    Instrument scoring                                    Support
              Outcomes tracking
              Automated Treatment Recommendations




Assessments                                                      Progress Notes
                        Assembling the
                         Components

                                       Evidence-Based
          Story Board
                                          Protocols




                    Database       Trial       Instruments
User Interface
                    Structure   Management      and Scripts


            Panel                        Decision
         Management                      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

				
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