Q: Why can’t we use our EHR?

A: EHRs have limited functionality

•EHRs do not allow a care manager to quickly see all the patients they are currently treating which is needed to provide POPULATION-BASED care.

•EHRs cannot quickly summarize which patients are NOT improving which is needed for TREATMENT-TO-TARGET CARE.

•EHRs cannot generate caseload statistics about the number of patients improving and other quality measures which are required for ACCOUNTABLE CARE.

•EHRs will not provide all the information you need to report to the Department of Health for your Medical Home Demonstration Home funding (grid of requirements is below).

Q: Can we reconfigure our EHR to provide the needed information?
A: Maybe. EMRs can sometimes be designed to cue specific clinical activities but this is not a core feature and typically requires a significant investment in customization of both time and money.

Q: How much will CMTS cost?
A: Nothing. CMTS is free for you to use during and beyond this project. It can cost upwards of $50,000 to purchase separately.
Q: Is CMTS HIPPA compliant?

A: Yes. Accessibility to PHI is limited to users with proper authorization and this is controlled by each organization, not the UW AIMS Center.All other users will only see de‐identified information using a CMTS assigned Patient ID. The other users are controlled by each organization, not the UW AIMS Center.

Q: Will using CMTS mean lots more work?

A: No. Most care mangers will need to do some double documentation (usually 1-5 minutes extra per patient). However, you will gain efficiency in being able to:

•Quickly assess and triage your entire caseload

•Consult on more patients, more easily

•Get more patients better AND faster to provide PATIENT-CENTERED CARE!

Q: Do I have to enter all the items for the PHQ-9 individually?

A: Yes. The answers to the individual questions are clinically relevant.View the 6/27 webinar for more information:

Q: We currently use Excel to track patients. Can we export our information into the CMTS?

A: No. You will need to copy/paste or type the patient data you want to put in the registry.

Q: Can the AIMS Center delete fields from the CMTS that we don’t want to use?

A: No. However, you do not need to fill out all the fields. Only fill out the fields that are useful to you.

Q: Can I add a next appointment without knowing the time of the appointment?

A: No. “Next appointment” is NOT a required field, so leave it blank if you don’t yet know the time. If you want to use this field for something else, likerecommendingthe patient come back in two weeks, you can type that into the note. Remember that CMTS will automatically prompt you to follow-up after 14 days if the patient’s PHQ-9 is 10 or above and after 28 days if it is less than 10.

Q: What information will need to come out of CMTS for our DOH reports?

A: See the highlighted cells below

Integration of Physical-Behavioral Health Care (Collaborative Care Initiative)

Measure Name / Definitions / Values / Rate / Measure Identification Number / Data Source
Controlled Substances / Numerator definition:: Number of prescriptions for Schedule II-IV of controlled substances written at the outpatient site for which the prescriber checked the NYS Prescription Drug Monitoring Database.
Denominator definition:All prescriptions written for controlled substances at the outpatient site. / Numerator::
0
Denominator:
0 / 0 / NYS Legislation / Other
iSTOP begins Aug 27, 2013
Depression and Pain Management / Numerator definition:: Number of primary care clinicians at the outpatient site who have completed a training program in pain management and depression.
Denominator definition:All primary care clinicians at the outpatient site. / Numerator::
0
Denominator:
0 / 0 / Per Work Plan / Other
Certificate of completion
Per Office of Mental Health / Numerator definition:: Number of patients enrolled in the Collaborative Care Initiative whose PHQ-9 went from at >10 to <10 in 16 weeks or greater.
Denominator definition:All patients enrolled in the Collaborative Care Initiative. / Numerator::
0
Denominator:
9999 / 0 / AIMS Collaborative / Other
Per Office of Mental Health / Numerator definition:: Number of patients enrolled in the Collaborative Care Initiative referred for psychiatric consultation*.
Denominator definition:All patients enrolled in the Collaborative Care Initiative. / Numerator::
0
Denominator:
9999 / 0 / AHRQ / Other
Per Office of Mental Health / Numerator definition:: Number of patients enrolled in the Collaborative Care Initiative still receiving medication and/or psychotherapy six (6) months after enrollment.
Denominator definition:All patients enrolled in the Collaborative Care Initiative. / Numerator::
0
Denominator:
9999 / 0 / AHRQ / Other
Per Office of Mental Health / Numerator definition:: Number of patients screened positive from the outpatient site who were then diagnosed with depression (eliminates false positives on screen).
Denominator definition:All patients from the outpatient site screened positive for depression. / Numerator::
0
Denominator:
9999 / 0 / AIMS Collaborative / Other
Per Office of Mental Health / Numerator definition:: Outpatient site staff care manager time (FTE equivalent) dedicated to chronic physical health management and to behavioral health care management.
Denominator definition:None / Numerator::
0
Denominator:
0 / 0 / AIMS Collaborative / Other
Per Office of Mental Health / Numerator definition:: Number of patients from the outpatient site screening positive for depression who enrolled in physical-behavioral health care coordination program (Collaborative Care Initiative).
Denominator definition:All patients from the outpatient site screened positive for depression. / Numerator::
0
Denominator:
9999 / 0 / AIMS Collaborative / Other
Per Office of Mental Health / Numerator definition:: Number of adult patients per year from the outpatient site who received a PHQ-2 or a PHQ-9.
Denominator definition:All patients from the outpatient site. / Numerator::
0
Denominator:
9999 / 0 / AIMS Collaborative / Other
Wait Times for Behavioral Health Services / Numerator definition:: Number of patients from the outpatient site needing behavioral health services seen within the timeframe requested by the primary care provider.
Denominator definition:All patients from the outpatient site being referred. / Numerator::
0
Denominator:
0 / 0 / Per Work Plan / Medical Record

* A psychiatric consultation in Collaborative Care is different from a traditional consultation. It can occur between the Psychiatric Consultant and the Care Manager, the Psychiatric Consultant and the PCP, as well as the Psychiatric Consultant and the Patient. The Psychiatric Consultant supports the PCP and Care Manager in treating patients with behavioral health problems. He/she typically meets with the Care Manager weekly to review the treatment plan for patients who are new or who are not improving as expected. Psychiatric consultations are largely done via phone with the Care Manager (and sometimes the PCP), and typically involve the discussion of 4-6 patients. During a consultation, the Psychiatric Consultant may suggest treatment modifications for the PCP or Care Manager to consider, recommend that he/she see the patient for an in-person consultation, or suggest that the patient be referred to specialty mental health services. Direct consultations can be performed face-to-face or using tele-video equipment. Typically, less than 10% of patients should need direct consultation.