Depression CDSS

Charles Kitzman, Barbary Baer, Sudha Poosa

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The Project

To maximize BH efficiencies while maintaining quality care

Workflow optimization FQHC integrated BH model Strategic partnership Continuity of care/chart sharing Advanced primary care practice

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Environment

FQHC northern CA county Woefully inadequate BH services

PH contractual outpatient Demand > Access Obligation to have streamlined services Filter inadequate referrals Time for appropriate patients

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Backdrop

Higher rates for Suicide >50% 65 or older

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Conditions leading to death -rates in Shasta County

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County crisis stabilization

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Rank by county

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Bottling the ends

Our approach sought to narrow scope Why? It’s a diverse field with lots of

variability. Makes it difficult to study Many tools, many interpretations Depression is our focus PQH-9 and lab results respectively

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Rationale for screening

Only half of depressed patients are diagnosed by their primary care physician

Patients with serious mental illness are 23% more likely to have a non-psychiatric hospitalization compared to the rest of the population. At $6000/admission, this adds $16 million to California’s Medi-Cal program

Depression is associated with greater health service use, greater morbidity & mortality, increased medical costs, not to mention unnecessary suffering

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Screening Triggers

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PHQ-9

Advantages Self-administered Freely available Short (9 items) Has been validated in Spanish

Sensitivity: from 94.4% (cutoff point >= 9) to 88.9% (cutoff point >= 13) Specificity: from 73.3% (cutoff point >= 9) to 86.7% (cutoff point >= 13)

Original study: Sensitivity for major depression: 88% for scores > 10 Specificity for major depression: 88% Scores of 5, 10, 15, 20 represented mild, moderate, moderately

severe, severe depression respectively

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PHQ-9 Questionnaire

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Depression CDSS flowchart

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Depression CDSS Mindmap

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System : Input

Demographics Chief complaint HPI (History of present illness)

Other illnesses Medications Life events

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System : Architecture and Interface

Enterprise wide client-server based architecture Architecture will comprise database and the rules engine Compliant with standards – HIPAA, LOINC, HL7, etc. Use of drop menus and logic checks Use of clinic reminders and alerts Capability of creating individual care plans with self-

management information and disease severity rating Linked with, but not a substitute for electronic medical

records. Will be integrated at the point of care PHQ-9 entry can be made by the patient, nurse or the

clinician

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System : Output & Workflow

Context-specific decision support in real time

Test score & risk stratification

Treatment regimen Whom to refer the patient to (level of BH clinician)

When should the patient be tested / re-evaluated

When to administer medications to the patient

Treatment options No treatment

Watchful waiting

Psychotherapy / counseling

Anti-depressant medication

Combination therapies

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System : Output & Workflow

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Evaluation

Audit of inappropriate referrals with an expectation of declining numbers

Increased access or an increase in encounters per clinic hour for BH staff

Increase in consistent use of screening tools by PC staff

Log trigger results to check provider compliance with tool suggestions

Better outcomes

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Conclusions

Difficult to separate operations from clinical decision piece

BH is very complex field to understand Actually will beta-test in the clinic with a few

providers

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Q & A