Using Information Technology to Provide Measurement Based Care for Chronic Illness (Texas)

Project Final Report (PDF, 1.46 MB) Disclaimer

Using Information Technology to Provide Measurement Based Care for Chronic Illness - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS07-006: Ambulatory Safety and Quality Program: Improving Quality Through Clinician Use of Health Information Technology (IQHIT)
  • Grant Number: 
    R18 HS 017189
  • Project Period: 
    September 2007 - February 2011
  • AHRQ Funding Amount: 
    $1,196,703
  • PDF Version: 
    (PDF, 187.56 KB)

Summary: Depression is the most common mental health cause for disability, and treatment should consider the chronic nature of the disorder. Current routine practice in psychiatric settings does not depend on a systematic measurement-based approach to treatment planning but on clinical judgment. Despite the development of effective treatments over the last 30 years, evidence from practice settings continues to show inadequate antidepressant medication treatment in dosage and duration. This project applied expertise in algorithm and guideline implementation to the development of a clinical decision support system (CDSS) integrated with an electronic health record (EHR) to disseminate the principles of evidence-based treatment for depression in large systems of care.

The project focused on the use of measurement-based care (MBC) to improve the quality of care for patients with major depressive disorder (MDD). The EHR-CDSS program facilitated MBC to improve medication management for patients with MDD by using information technology (IT) to ensure that clinicians monitored three critical response domains (symptom severity, side-effect burden, and treatment adherence) using standardized measures. The IT system also provided decision support during each medication treatment phase and helped prevent medication errors.

This project was a collaboration between the University of Texas Southwestern Medical Center and the Centerstone Community Mental Health Center, Inc. (Centerstone), which provides behavioral health services throughout Tennessee. The first phase of the project was primarily devoted to customizing the CDSS to accommodate Centerstone's specific needs and integrating CDSS into Centerstone's EHR, CenterNet. The objective of the second phase was to test the effectiveness of the EHR-CDSS to increase clinicians' use of MBC principles in medication management for patients with MDD.

This project involved two research studies to evaluate effectiveness of the EHR-CDSS. The first study was a comprehensive, system-wide evaluation that included clinicians using the EHR-CDSS and their MDD patients who required a treatment change, either in medication or in dosage. The second study was an in-depth evaluation of the impact of the EHR-CDSS on a limited sample of physicians and their patients, directly assessing the use of MBC using a pre-post test design.

Specific Aims:

  • Integrate a CDSS that facilitates MBC with physician needs and the EHR at Centerstone. (Achieved)
  • Evaluate EHR-CDSS's successful promotion of MBC in improving medication management. (Achieved)

2011 Activities: The 6-month no-cost extension period ended February 2011. All project activities were completed

Impact and Findings: A needs assessment was conducted with representative Centerstone clinical staff members to determine how best to integrate the CDSS and EHR. Their primary concern was the increased time burden, in both the length and number of treatments visits. Based on prior reports, the research team expected that providing MBC would initially require more time, but once the system was established, the increased visit time would primarily involve the time the patient needed to complete the self-report assessments. Data showed that while patients in the algorithm arm of the trial initially were seen at a higher frequency, the total number of visits over a year were similar in both arms of the trial.

The first study was designed to provide a systematic evaluation of changes in treatment patterns in the Centerstone system before and after implementation of EHR-CDSS. There was a significant difference in both the total number of visits and the patterns of treatment visits. Additional analyses that explore differences based on decision support usages, length of time between visits, and the utilization of MBC assessments during treatment visits are ongoing.

Target Population: Adults, Chronic Care*, Mental Health/Depression

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve the quality and safety of medication management via the integration and utilization of medication management systems and technologies.

Business Goal: Implementation and Use

* This target population is one of AHRQ's priority populations.

Using Information Technology to Provide Measurement Based Care for Chronic Illness - 2010

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS07-006: Ambulatory Safety and Quality Program: Improving Quality Through Clinician Use of Health Information Technology (IQHIT)
  • Grant Number: 
    R18 HS 017189
  • Project Period: 
    September 2007 – February 2011, Including No-Cost Extension
  • AHRQ Funding Amount: 
    $1,196,703
  • PDF Version: 
    (PDF, 739.32 KB)


Target Population: Adults, Chronic Care*, Mental Health/Depression

Summary: Current routine practice in psychiatric settings does not depend on a systematic measurement-based approach but on global clinical judgment. This approach often results in suboptimal care and outcomes. Depression is the most common mental health cause for disability, and treatment should consider the chronic nature of the disorder. Despite the development of effective treatments over the last 30 years, evidence from practice settings continues to show inadequate antidepressant medication treatment in terms of dose and duration. This project applies expertise in algorithm and guideline implementation to the development of a clinical decision support system (CDSS) integrated with an electronic health record (EHR) with the goal of disseminating the principles of evidence-based treatment for depression in large systems of care.

The project focuses on the use of Measurement Based Care (MBC) to improve the quality of care for patients with major depressive disorder (MDD). The EHR-CDSS program will facilitate MBC to improve medication management for patients with MDD by using information technology (IT) to ensure that clinicians are monitoring three critical response domains (symptom severity, side-effect burden, and treatment adherence) using standardized measures. The IT system will also provide decision support during each medication treatment phase and will help prevent medication errors.

This project is a collaboration between the University of Texas Southwestern Medical Center and the Centerstone Community Mental Health Center, Inc. (Centerstone). Centerstone is a behavioral health services provider that provides treatment throughout Tennessee. The first phase of the project was primarily devoted to customization of the CDSS to take into account the specific needs of Centerstone and integration of CDSS into Centerstone?s EHR, CenterNet. The objective of the second phase was to test the effectiveness of the EHR-CDSS to increase clinicians? use of MBC principles in medication management for patients with MDD.

To fully evaluate effectiveness of the EHR-CDSS, this project involves two research studies. The first study is a comprehensive, system-wide evaluation that will include clinicians using the EHR-CDSS and their patients with depression who require a treatment change, either a change in medication or an increase in dose. The second study is an in-depth evaluation of the impact of the EHR-CDSS on a limited sample of physicians and their patients, directly assessing the use of MBC using a pre-post test design.

Specific Aims:
  • Integrate a CDSS that facilitates MBC with physician needs and the EHR at Centerstone. (Ongoing)
  • Evaluate EHR-CDSS?s successful promotion of MBC in improving medication management. (Ongoing)

2010 Activities: The integration of the EHR-CDSS and implementation of MBC started in February 2010 and was instituted in 21 clinics (14 rural and 7 urban) that treat approximately 8000 patients with MDD. Data collection was ongoing through the end of the year.

Most Recent Self-Reported Quarterly Status (as of December 2010): The grantee did not provide self reported status.

Impact and Findings: As a first step, a needs assessment was conducted with representative Centerstone clinical staff members to determine how best to integrate the CDSS and EHR. The primary concern expressed by clinical staff members is the increased time burden, in terms of both the length of the treatment visit and the number of treatments visits. Based on prior reports, the research team expected that providing MBC would initially require more time, but once the system was established, the increased visit time would primarily involve the time the patient needed to complete the self-report assessments. Data showed that while patients in the algorithm arm of the trial initially were seen at a higher frequency, the total number of visits over a year were similar in both arms of the trial.

The first study was designed to provide a systematic evaluation of any changes in treatment patterns in the Centerstone System before and after implementation of EHR-CDSS. There was a significant difference in both the total number of visits as well as the patterns of treatment visits. Additional analyses that explore differences based on decision support usages, length of time between visits, and the utilization of MBC assessments during treatment visits are ongoing.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve the quality and safety of medication management via the integration and utilization of medication management systems and technologies.

Business Goal: Implementation and Use

*AHRQ Priority Population

Project Details - Ended

Project Categories

Summary:

Following the work of the Texas Medication Algorithm Project – a previous study funded by multiple funders, including the National Institute of Mental Health and the Robert Wood Johnson Foundation – the Sequenced Treatment Alternatives to Relieve Depression Trial developed the concept of measurement-based care (MBC) as a way to facilitate evidence-based care of depression. Elements of MBC include: 1) standard assessments of symptoms, function, and side effects; 2) use of critical decision points based on a state-of-the art algorithm for major depressive disorder (MDD); 3) consistent patient followup; and 4) performance feedback for clinical decisionmaking. The merging of MBC strategies with existing technology has been theorized to improve quality of care and outcomes of depression by maximizing delivery of appropriate treatment for MDD in ambulatory care settings, making it possible to electronically monitor whether there is consistent use of treatment practices that have been shown to be effective, as well as making MBC strategies accessible and user-friendly for medical providers. 

This electronic health record (EHR) clinical decision support system (CDSS) program was a collaboration between the University of Texas Southwestern Medical Center and the Centerstone Community Mental Health Center, Inc. The EHR-CDSS was instituted in 21 clinics and designed to facilitate MBC and improve medication management for patients with MDD to ensure that clinicians were using standardized measures to monitor three critical response domains: 1) symptom severity, 2) side-effect burden; and 3) treatment adherence. The specific aims of the project were to:

  • Integrate a CDSS, facilitating MBC, with physician needs and the EHR at Centerstone.
  • Evaluate EHR-CDSS's successful promotion of MBC in improving medication management.

In order to develop an EHR_CDSS that could effectively implement MBC, the project consisted of a three-stage process. Stage 1 was an end-user needs assessment that provided information about the needs of both the physician and the Centerstone care system. Stage 2 included a modification of the CDSS based on the information from the needs assessment. Finally, Stage 3 included the development of the CDSS to interface with Centerstone’s EHR.

The project team evaluated the extent to which implementation of the EHR-CDSS promoted the use of MBC as standard care for depression in both rural and urban settings. Two studies were conducted to evaluate the effects of using an EHR-CDSS to institute MBC. The first study looked at the impact across the entire health care system; the second was an in-depth evaluation of treatment practices and their effects in a sample of patients being treated for MDD.

Of 289 Centerstone employee surveys, 208 were analyzed as part of the needs assessment. This assessment revealed concern that the research would increase the time burden for Centerstone clinicians. Implementation results showed no statistical differences between baseline and week 24 with regard to any of the three outcome domains. However, the pattern of the results was encouraging and symptom decreases were seen early in the course of the study, following the pattern of similar studies.

Using Information Technology to Provide Measurement Based Care for Chronic Illness - Final Report

Citation:
Trivedi M. Using Information Technology to Provide Measurement Based Care for Chronic Illness - Final Report. (Prepared by the University of Texas Southwestern Medical Center under Grant No. R18 HS017189). Rockville, MD: Agency for Healthcare Research and Quality, 2010. (PDF, 1.46 MB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
Principal Investigator: 
Document Type: 
Medical Condition: 
This project does not have any related resource.
This project does not have any related survey.
This project does not have any related story.
This project does not have any related emerging lesson.