Information technology to support improved care for chronic illness
DRAFT -- DO NOT CITE OR DISTRIBUTE
Appendices
Use cases
1. Depression
2. Schizophrenia
3. Diabetes with comorbidity
Use Case: Depression
Creating Health Informatics Applications for Collaborative Care (CHIACC)
Draft: June, 2006
Contact: Edmund Chaney () or Laura Bonner ()
Name: Depression collaborative care management
Goal: Implementation of evidence-based depression care
Purpose: The treatment team including the primary care (PC) provider, depression care manager (DCM) and as needed, mental health specialist will be able to track and treat a panel of patients with depression over time using structured assessment tools and will communicate with patients and providers about clinical issues.
Business case: Depression care consumes significant resources. It is important to implement a cost-effective, evidence-based treatment to optimize use of limited resources.
Overview: During a primary care visit, PC providers (or their delegates) screen patients for depression. Screening may be formal (required administration of PHQ2 / PHQ9) or informal (information generated during clinical discussion with patient). PC providers then refer to the DCM (this may be required and built into the informatics system based on PHQ responses, or may be less formal; this process is customizable to meet local needs). Depression care managers call screen-positive and/or referred patients, educate them about depression, address side effects, maintain contact with referring primary care clinicians and provide ongoing feedback to primary care providers as appropriate. Aggregated information is available to clinic managers for program evaluation purposes.
Actors: Primary care (PC) providers diagnose depression and initiate a treatment plan, which includes referral to a care manager.
Depression care managers(DCM) provide ongoing assessment of patients and communicate with consulting specialists and referring providers.
Mental Health Specialists provide supervision and consultation to depression care managers and referring primary care providers about challenging cases.
Patients seek treatment from primary care providers and work closely with depression care managers to assess progress and address concerns or questions.
Clinic managers review program function and make strategic decisions.
Triggers: A primary care provider diagnoses depression, or a patient screens positive for depression on automated screening. The provider refers the patient to care management. The PC provider may or may not prescribe antidepressant medication depending on clinical judgment.
Typical Course of Events:
- Primary care provider: On Monday morning, the primary care provider, Dr. Nguyen, has an appointment with JimJohnson who is due for his automated two-item depression screen. Screen responses populate a depression registry. A collaborative care consult is built into the screening reminder. When Mr. Johnson responds “yes” to one of the trigger questions, a screen pops up asking Dr. Nguyen if he wishes to send a consult to Mary, the DCM. Based on Mr. Johnson’s response to this question, his affect as observed by Dr. Nguyen, and his elaboration that sometimes it is very hard for him to feel happy, Dr. Nguyen becomes concerned that Mr. Jones may have depression. Dr. Nguyen decides that the patient would benefit from further assessment by the DCM. So, Dr. Nguyen sends an electronic consult to Mary. This process constitutes a referral to the TIDES program. Dr. Nguyen decides not to initiate antidepressant medication until he knows more about the patient’s symptom severity and treatment preferences. These issues can be further explored by the DCM. Dr. Nguyen has been informed that referral to TIDES would not be appropriate for a patient with acute suicidal ideation or certain other comorbidities.
- Depression care manager: Mary uses a panel management tool (PMT) based on the depression registry database to prioritize and track her depression care management activities. She sees that Dr. Nguyen has sent her a consult. She calls Mr. Johnson and introduces herself as a nurse who works with Dr. Nguyen. She tells him that the assessment will take about 40-45 minutes. Mary uses an electronic data entry form to enter structured information as she asks the questions on the PHQ-9depression symptomatology measure. Mr. Johnson scores 16 (in the depressed range), so Mary proceeds to the flexibly and hierarchically structured Initial Assessment. At the conclusion of the assessment, Mary tells Mr. Johnson that she will summarize their discussion for Dr. Nguyen who may want her to contact him several more times, especially if Mr. Johnson begins antidepressants, for which he expressed a preference. Mr. Johnson agrees to further contact. During the assessment, Mr. Johnson reported problems with sleep, frequent feelings of anxiety, and a lack of pleasurable activities in his life. Mary uses the PMT to mail him some educational materials that address these concerns. Mary uses the PMT to schedule the next call for the patient. The PMT outputs evidence-based treatment suggestions based on the patient’s responses that Mary customizes using her clinical judgment. Mary can enter clinic treatment resources into the decision-support module. For instance, if the clinic has a depression education group and/or a CBT group, recommendations for these can be generated based on Mary’s evaluation and the patient’s preferences.
- Communication between providers: At the end of her encounter with Mr. Johnson, Mary completes the consult by reviewing the note her data entry program has prepared from her interview information. The consult note lets Dr. Nguyen see her primary findings and Mr. Johnson’s treatment preferences. The consult note also directs Dr. Nguyen to a longer progress note containing the substance of the full assessment. Because certain problems, such as sleep disturbance and anxiety, commonly co-occur with depression, the progress note includes a box listing these problems for quick reference by the provider. The note is structured so that Dr. Nguyen can immediately view the most recent PHQ-9 score, the current medications (if any), medication adherence (if medications are prescribed) and problems of special concern to the patient.
- Primary care provider: Dr. Nguyen reviews the brief note, agrees that Mr. Johnson would benefit from antidepressants, sends the order to the pharmacy (electronically), and uses the provider’s PMT version to notify Mr. Johnson that his antidepressants can be picked up. Dr. Nguyen’s PMT version has an optionally displayed decision support function to check the latest context sensitive evidence-based treatment recommendations.
- Depression care manager: Mary enters a treatment plan, documenting the decisions made by Dr. Nguyen, the patient, and the DCM about the patient’s goals and treatment. After one week, Mary’s PMT alerts her that it is time to call Mr. Johnson to ensure that he has picked up his antidepressants and begun taking them. Mary checks pharmacy records to ensure that Mr. Johnson has picked up his medications. She calls and also administers the PHQ-9 again. During their 15 minute conversation, Mr. Johnson expresses concern about some side-effects. Mary tells him that she will mail him some information about side effects, and lets him know that they can talk about ways of handling side effects. Mary also specifically prompts the patient to discuss the problems he identified during the initial call (in this case, his sleep disturbance and anxiety). She provides education to the patient about sleep hygiene and about techniques for relaxation. She then arranges to call him again in one week, and uses her data entry software to document the call. The software produces a text note which she reviews and adds Dr. Nguyen as an additional signer to her note.
- Depression care manager (patient interaction): When Mary calls a week later at the scheduled time, Mr. Johnson’s PHQ-9 is unchanged and he reports that he is not taking his antidepressants every day because of the side effects. Mary reinforces the importance of taking his medication regularly, and she and Mr. Johnson discuss a number of different ways of handling his side effects. She reminds him to review the information that she sent in the mail and he agrees to do so and take his medication in the future. She then schedules a call for the following week. This is a brief call, during which Mr. Johnson reports that he is taking his antidepressants as prescribed.
- Depression Care Manager (patient interaction): One month later, Mary conducts her pre-call chart review using a view tool that organizes relevant information for her in preparation for her call to Mr. Johnson. At this time, she discovers that he did not keep his last appointment with Dr. Nguyen and did not refill his antidepressant prescription. During the call, Mr. Johnson’s PHQ-9 score again shows no improvement, and he states that he did not take the medication every day because of the side effects. Also, he continues to have problems with sleep and anxiety. Mary again provides patient education about reducing side effects and refers him to patient-oriented websites on depression. After scheduling their next appointment, Mary uses the PMT to make a note to consult with the supervising psychiatrist about whether a medication change or other changes would be advisable.
- Documentation of clinical information: As in previous encounters, the PHQ-9 and the other responses were entered into the Electronic Medical Record (EMR) for follow-up assessments that provide both the script to follow and response fields to complete. When the note title was selected, it appeared as an almost complete documentation of the encounter with the content organized so that Dr. Nguyen, who was again included as an additional signer, could see the most important information at the beginning of the note, including the PHQ-9 score, medication compliance, and patient comments or concerns.
- Consultation/supervision: When Mary meets with Dr. Smith, the supervising psychiatrist, he and she use PMT output to structure their treatment review. He recommends a change in Mr. Johnson’s treatment plan. The plan is to continue to treat depression in primary care through a medication change. Mary alerts Dr. Nguyen, who is in full agreement and makes the change. If Mary and Dr. Smith are concerned that more intensive treatment is indicated, with Dr. Nguyen’s concurrence, a stepped care consult is made to the appropriate mental health specialty program. If Dr. Nguyen had wanted to discuss the recommendation, he could use a secure off-record communication utility, documenting the final agreed-upon plan in the EMR.
- Tracking progress: On a scheduled call a month later, Mr. Johnson reports that he’s feeling more like himself again. His PHQ-9 is down to 11, and he and Mary are both pleased by his progress. His sleep has improved significantly. He continues to experience anxiety but feels it happens less frequently than before. Mary encourages Mr. Johnson to keep doing what he’s doing since it’s so clearly working. He agrees that their next call will be in two months. Mary documents the call and schedules their next appointment. Mary prints out a graph of Mr. Johnson’s PHQ-9 scores over time. Scores are color-coded by medication, so that the relationship between medication initiation and changes can be easily visualized.
- Follow-up appointment: Mr. Johnson receives the automated appointment reminder, which was very important since his last call was so long ago he had completely forgotten about it. He is waiting at the phone when Mary calls. His PHQ-9 is now down to 6. Mr. Johnson says that he’s feeling so well now that he’s been thinking about stopping the antidepressants. Mary counsels him to continue taking them. Not only could he feel even better yet, but it’s important to remain on antidepressants for at least 6 months after total remission of symptoms in order to ensure that they don’t come back. Mary schedules their next and final call for 6 weeks from then, documents the call, and enters the next appointment into the PMT.
- Post-conditions: At their next call, Mr. Johnson scores a 2 on the PHQ-9! He is truly delighted. Mary introduces the concept of relapse prevention and they discuss preparations for difficult events to come, and how Mr. Johnson can use the PHQ-9 on his own as a monitoring tool. He will continue to take his antidepressants for 6 more months and will then discuss tapering off of them with Dr. Nguyen. If he is concerned at any time that he is feeling depressed again, he will first contact Dr. Nguyen, but can also contact Mary. Mary will send him some additional materials on relapse prevention immediately and again, when prompted by the PMT, in a couple months. Both are confident that Mr. Johnson will do well. Mary documents the end of Mr. Johnson’s depression management, as usual listing Dr. Nguyen as a co-signer on the consult note.
- Program Evaluation:Monthly, Mary meets with the clinic depression care clinic champion and they review an aggregated report prepared by her PMT that shows information such as which providers have been referring, the relationship between her panel workload and the call frequency protocol, ratio between patients managed in primary care and referred to specialty mental health, consult completion rate and PHQ9 change scores grouped by presence of particular comorbidities. They use this information to decide on whether additional provider education is called for, to prepare for the upcoming JCAHO audit and to put a poster together to document the gains made in treatment efficiency, improved quality of care and patient quality of life.
Use Case: Schizophrenia
Creating Health Informatics Applications for Collaborative Care (CHIACC)
Draft: June, 2006
Contact: Alexander Young () or Amy Cohen ()
Name: Schizophrenia chronic care management
Vision: Implement effective treatment for schizophrenia, according to national treatment guidelines. Use implementation approaches supported by Mental Health QUERI.
Business Case: The President’s New Freedom Commission calls for broad implementation of recovery-oriented and evidence-based services. In schizophrenia, these services are often not used at present, and it is difficult to know how many patients should be offered these services. Since resources are limited, implementation efforts will need to be carefully targeted and the value of mental health services strongly justified.
Purpose: Improving care for schizophrenia has been quite difficult, in part because critical domains of treatment process and outcomes are not documented in routine medical records. Better information will be required to guide implementation efforts and individual clinicians’ treatment choices. Under a chronic care model, a team of managers and clinicians tracks a panel of patients over time using structured assessment tools. Clinicians have access to critical information at the point of contact with the patient. The team can identify specific patient groups by needs (i.e., psychosis, medication side-effects, caregiver service needs, unemployment). Policy-makers and administrative leaders are able to assess met and unmet patient needs across clinics and by provider.
Overview: Care managers, often a nurse, manage a panel of patients. They ensure that patients are routinely assessed with regard to symptoms, medication side-effects and functioning. They work to ensure appropriate referrals and follow-up, and facilitate communication among the care team. The care team has access to both current and past assessments, decision support, and referral information for access to services.
Actors: Care managers oversee ongoing assessment of patients and communicate with psychiatrists and other treating clinicians.
Patients have schizophrenia or schizoaffective disorder.
Psychiatrists are the primary physicians responsible for care.
Managers review clinic operations and treatment quality.
Trigger: A physician makes a diagnosis of schizophrenia. The patient is assigned to a specialty mental health clinic, and simultaneously referred to a care manager.
Typical Course of Events: (IT tasks are in italics)
Mark is a 48 year-old man with schizophrenia who has received his healthcare at a Veterans Administration (VA) MedicalCenter for the past 20 years. He lives with his brother and his brother’s wife and two teenage sons. He has received no care for the past 6 months, and is becoming more psychotic. His brother recently convinced him to re-start treatment.
Initial assessment: A time is scheduled for Mark to meet with a psychiatrist and the Care Manager (CM) at the mental health clinic. He attends this meeting, and meets first with the CM. The CM enrolls Mark in a schizophrenia patient registry. This registry is web-based, and linked with the Electronic Medical Record (EMR). Data entered into the registry and EMR includes current contact information for Mark, the names of his primary psychiatrist, social worker, and any other clinician involved with his care, his height, demographics, and any comorbid medical and substance abuse problems. The CM explains to Mark that the clinic has each patient complete a confidential, computerized assessment each time they come to the clinic. The CM shows Mark the computerized assessment kiosk and helps him complete his first assessment. This self-assessment includes questions about Mark’s current symptoms, side-effects, family relationships, functioning, and vocational status. The computer reads the questions to Mark (using headphones) and he answers using a touch-screen computer. The computer directs him to step on the scale next to the computer and enter his weight, which he does.The self-assessment is automatically turned into a note in the EMR with an alert for a signature from Mark’s psychiatrist. She can edit the note before signing.