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Implementation and Dissemination of Alcohol Screening and Follow-up Using Tools in CPRS/VistA. Katharine Bradley, MD Dan Kivlahan, PhD Carol Achtmeyer, MN, ARNP Emily Williams, MPH Gwen Lapham, MSW Supported by NW HSRD; RWJ Foundation; SUD QUERI; CESATE; VA Puget Sound. Overview.

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implementation and dissemination of alcohol screening and follow up using tools in cprs vista

Implementation and Dissemination of Alcohol Screening and Follow-up Using Tools in CPRS/VistA

Katharine Bradley, MD

Dan Kivlahan, PhD

Carol Achtmeyer, MN, ARNP

Emily Williams, MPH

Gwen Lapham, MSW

Supported by NW HSRD; RWJ Foundation; SUD QUERI; CESATE;

VA Puget Sound

overview
Overview

Implementation of 2Two CPRS Clinical Reminders

Alcohol screening

Follow-up positive alcohol screens

outline
Outline

Background alcohol misuse

VistA/CPRS components and approaches used

Clinical reminders

Health factors

Mental health package

Clinical informatics expert

Case Study #1 - Screening

Local  National

Case Study #2 - Brief alcohol counseling

Local  Regional  National

Next steps

background
Background

Alcohol misuse is common & large health burden

Evidence supports preventive focus

Brief alcohol counseling interventions effective

Target population: patients with risky drinking

Advice and feedback decrease drinking

3rd highest US Prevention Priority-Solberg 2008

Limited implementation of brief alcohol counseling

slide5
Alcohol Screening in VA Prior to 2003

Original performance measure (PM)

PM required any standardized screen

Almost all used CAGE

Identifieslifetime alcohol use disorders

Does not indicate if patients drink

Not the target population for brief alcohol counseling

Background

incremental implementation
Incremental Implementation

2000 AUDIT-C clinical reminder (CR) - 1 site

2001 Development CR for Follow-up – 1 site

2002 Pilot Study of Follow-up CR – 1 site

2003 New screening Performance Measure

2003 National screening CR: AUDIT-C

2004 Adoption of Follow-up CR by large VA

2007 Screening PM modified

2007 National PM for Follow-up Positive AUDIT-Cs

2008 National Follow-up CR disseminated

key concepts
Key Concepts

Required for HIT implementation

  • System and HIT readiness (at same time)
  • Linkage between researchers/HIT developers and informatics, clinical, and QI leaders
  • Clinical informatics expert on research team
  • Creative financing – not on project timeline
  • Greenhalgh model (2004) has been helpful understanding success and failures
cprs vista tools for implementation research
CPRS/VistA Tools for Implementation Research

Intro to Clinical Reminders (CRs)

CPRS Clinical Reminders can …

Alert providers to clinical care due

Educate providers

Provide decision support

Document care

Be shared between facilities

Provide data for performance monitoring

Activated for specific providers

CR reports can monitor in real time

slide9
Intro to CPRS Clinical Reminders

Provider Opens Progress Note

Provider MAY open Reminders Window

slide10
Intro to CPRS Clinical Reminders

Progress Note

Provider MAY choose to address follow-up for a positive alcohol misuse screen

slide11
Intro to CPRS Clinical Reminders

Clicking on Reminders Button and CR name brings up reminder dialog

slide12
Intro to CPRS Clinical Reminders

Decision Support

Health Factors are sent to VistA when boxes are clicked

slide13
Health factors

Can be attached to specific actions in CRs and used to monitor CR activity

Are not standardized, so vary across sites and over time

Stored locally in VistA, in some regional data warehouses and CDW

Mental Health Assistant (MHA)

Standardized assessment instruments

Scored automatically

Standardized data

Data stored in local VistA, eventually Pittsburg

CPRS/VistA Tools for Implementation Research

slide14
CPRS/VistA Tools for Implementation Research

CPRS GUI

Clinical

Reminders

VistA Files

Prog.Notes

Health Factors

MH Package

Pharmacy

Labs

clinical informatics expert
Clinical Informatics Expert

Prescribing clinician

Familiar with basic VistA and CPRS functions

Knew local programmers

Entrepreneurial

Initial role: project-oriented

Evolved to multiple roles

Builds clinical reminders, order sets etc.

Monitoring developments in CPRS

Networking within informatics community

Identify/develop data sources

Obtaining VistA data

clinical informatics expert16
Clinical Informatics Expert

Staying on the “cutting edge”

Attend annual VeHU conferences, online trainings

Weekly calls on CPRS or Clinical Reminders

American Informatics Medical Association (AMIA)

Review research on VA CPRS

Maintaining access to CPRS

Service to local facility

Beta test new CPRS software

Creative Financing: non-VA funding, Clinical COE (CESATE); and QUERI core funds

slide17
Case Study #1

Screening Clinical Reminder

Local (2000-2007)

National (2004-2008)

Case Study #1

slide18
AUDIT-C

3-item screen (0-4 each): sum to 0-12

Identifies the target population for brief alcohol counseling

Described/validated in VA outpatients 1998

Case Study #1 - Alcohol Screening

slide19
AUDIT-Cinto the MHA

Papers shared with Office of Mental Health

2 AUDIT-Cs added to MHA (self-scoring)

Technical problems with MHA AUDIT-C

Could not be corrected locally

Case Study #1 - Alcohol Screening

slide20
Local Implementation of AUDIT-C

~ 2000

Local decision to use AUDIT-C

Based on review of evidence

Request for MH programmers to fix MHA AUDIT-C

Meanwhile local AUDIT-C CR built: not self-scoring

AUDIT-C in MHA for years with no use

Case Study #1 - Alcohol Screening

slide21
National Implementation of AUDIT-C

2003

Office of Quality and Performance (OQP) sought guidance for next steps

Among VA patients who had 4+ drinks/day

66% felt they needed services for drinking

Only 17% reported they got needed services

OQP educated: need to screen for risky drinking

Case Study #1 - Alcohol Screening

slide22
Invitation to give key national presentations

Quality Management Information Conferences (2)

Performance Measures Work Group (PMWG)

PMWG decides to require AUDIT-C in FY 2004

National demand for new informatics tools for self scoring AUDIT-C

Case Study #1 - Alcohol Screening

slide23
OQP convened call develop AUDIT-C clinical reminder

Content experts (researchers)

Research clinical informatics expert

National CR expert

Associate Chief Consultant for MH Informatics

OQP leader in charge of PM

Barrier: self scoring AUDIT-C still needed fixing

Case Study #1 - Alcohol Screening

slide24
Clinical informatics expert

Knew problems with MHA AUDIT-C’s

Boundary spanner

Barrier: AUDIT-C in MH package lacked response options for nondrinkers

Led to 2 step clinical reminder

Identify drinkers

Administer AUDIT-C

National expert built AUDIT-C CR

CR made available nationally

Case Study #1 - Alcohol Screening

slide25
Passive diffusion AUDIT-C in MHA

used 1.4 million times in 2004

Lack of “buy-in”

End-users not familiar with AUDIT-C

New paradigm: preventive counseling

FAQ posted by OQP  educated the field

SHEP survey used to evaluate

Problems in quality: nondrinkers and under reporting

Revised PM in 2007

Case Study #1 - Alcohol Screening

slide26
Facilitators

System readiness

Collaboration: researchers, informatics & clinical leaders

HIT tool is available when system is ready

Characteristics of the innovation  diffusion

Evaluation and feedback

Comparison of survey & clinical screening

Resulted in revised Performance Measure

Case Study #1 - Alcohol Screening

slide27
Barriers

HIT not ready when PM announced

Decision made to use 2 step screening: non-standard assessment of drinking

Initially unprepared for educational need

Problems with face validity of AUDIT-C

Lack of provider buy-in

Lack of awareness of the importance of how screening is completed (verbatim; private; non-judgmental)

Case Study #1 - Alcohol Screening

slide28
Follow-up Clinical Reminder

Local (2001-2005)

Regional (2004-2006)

National (2008)

Case Study #2

slide29
Local Pilot

Follow-up Clinical Reminder

Version 1 (2001)

Original idea

Simple feedback of screening results to providers; relied on CPRS programmers

CPRS expert hired to help  not feasible

CPRS expert clinical reminders

Version 1 clinical reminder content based on trials

Assumed provider would do full assessment

Focus groups

Case Study #2A – Follow-up Clinical Reminder

slide30
Follow-up Clinical Reminder

Version 1 (2001)

Modifications after focus group feedback

Simpler algorithm and help text

Only advice initially required

Escape option: “Will address at next visit”

Optional

Assessment: diagnostic criteria, labs, blood pressure, readiness to change

Intervention: patients goal, referral, etc.

Case Study #2A – Follow-up Clinical Reminder

slide31
Case Study #2A – Follow-up Clinical Reminder

Provider Education:

recommended

drinking limits

Provider Education: Components of BI

slide32
Case Study #2A – Follow-up Clinical Reminder
  • Provides Decision Support
  • Risk Stratify: Assess prior treatment and whether drinking above limits
  • Advise:required to “turn off” clinical reminders
  • Optional: Document giving feedback on medical problems linked to alcohol use, further assessment, or referral
slide33
Case Study #2A – Follow-up Clinical Reminder

Facilitates documentation

Each action clicked is documented in

progress note

Turns off clinical reminder if advice documented

Click “Finish” button

slide34
Local Pilot

Follow-up Clinical Reminder

(2003-2005)

Tested locally after revision

Primary care providers did not routinely use CRs

No specific training: email announcement only

Health factors from regional data warehouse

Low rates of use: 15%

Many noted would address alcohol at another visit

Case Study #2A – Follow-up Clinical Reminder

local pilot 2003 2005
Case Study #2A – Follow-up Clinical ReminderLocal Pilot (2003-2005)

Facilitators

  • Clinical informatics expert
    • Identified tools
    • Built and reiteratively revised clinical reminder
  • Early linkage with local end-users
  • 1:1 observation and focus groups key

Barriers

  • VA providers hard to recruit for focus groups
  • Low system readiness
slide36
National implementation of AUDIT-C screening 

“The field” wanted help with follow-up

National CR experts requested follow-up CR

One expert

Simplified and implemented the CR at 8 sites

Shared with other sites

Health factors simplified and changed

Used CPRS CR Reports to track

Submitted IRB application

Case Study #2B – Follow-up Clinical Reminder

Informal RegionalDissemination

slide37
Case Study #2B – Follow-up Clinical ReminderInformal RegionalDissemination

% Patients with Positive AUDIT-C whose Provider

Completed CR for Brief Alcohol Counseling

Bradley Substance Abuse 2007

slide38
Case Study #2B – Follow-up Clinical ReminderInformal RegionalDissemination

% Patients with Positive AUDIT-C whose Provider

Completed CR for Brief Alcohol Counseling

slide39
Evaluation

CR reports provide no detail on parts of CR used

CIE worked to get MHA data out of VistA (VeHU)

National fileman expert wrote Fileman query

CIE Tested locally, then sent to pilot site

Pilot site built locally  extracted data

ASCII file transferred server to server STATA

Health factor data difficult to interpret

*CIE=clinical informatics expert

Case Study #2B – Follow-up Clinical ReminderInformal RegionalDissemination

slide40
Case Study #2B – Follow-up Clinical ReminderInformal RegionalDissemination

Facilitators

  • System readiness
    • Performance measure for screening created demand for Follow-up CR at some sites
    • Primary care providers routinely used CR
  • CIE - Informal informatics networks
    • Improved/adapted clinical reminder
    • 2nd Pilot – 8 sites
    • Allowed us to get data from that site

Barriers

  • Finding MHA data
  • Health factor data edited; not distinct names
slide41
Case Study #2B-C – Follow-up Clinical ReminderImproving the CR for NationalDissemination

Quality Improvement before Dissemination

  • OQP consulted: Follow-up EPRP measures (6/2006)
  • Collaboration on Follow-up CR (5/2007)
    • OQP and OMHS
    • national CR expert CR
  • But no formative evaluation of CR yet!
    • How are providers using the CRs?
    • What needs fixing?
  • Hasty quality improvement interviews
  • Creative financing: CESATE
slide42
Dissemination

Clinical reminder adapted again

Further simplified based on interviews

Made consistent with performance measure

Fall 2007: sites could request CR from Office of Primary Care-Mental Health integration

Distributed nationally in CPRS CR patch 6, January 2008

Case Study #2C – Follow-up Clinical ReminderNational Dissemination

slide43
Case Study #2C – Follow-up Clinical ReminderNational Dissemination

Change Over Time in

Rates of Documented Brief Alcohol Counseling

* Among Patients with AUDIT-C > 5; p’s < 0.001

slide44
Case Study #2C – Follow-up Clinical ReminderNational Dissemination

Change Over Time in

Rates of Documented Brief Alcohol Counseling

* Among Patients with AUDIT-C > 5; p’s < 0.001

slide45
Case Study #2C – Follow-up Clinical ReminderNational Dissemination

Change Over Time in

Rates of Documented Brief Alcohol Counseling

* Among Patients with AUDIT-C > 5; p’s < 0.001

slide46
Case Study #2C – Follow-up Clinical ReminderNational Dissemination

Change Over Time in

Rates of Documented Brief Alcohol Counseling

* Among Patients with AUDIT-C > 5; p’s < 0.001

next steps
Next Steps
  • Standardize follow-up CR for electronic monitoring
  • Evaluate quality of brief alcohol counseling
    • Compare documented advice & patient report
  • Evaluate changes in drinking after counseling
    • Validate AUDIT-C as a measure of change
  • Compare quality across implementation strategies
    • B Yano’s Primary care survey
  • Work towards having MHA AUDIT-C
    • interact with the pharmacy package
    • inserted into pre-op templates
  • Chronic management alcohol dependence in CPRS
    • Patient lists, order sets, and templates
conclusions
Conclusions

Challenges for Implementation

  • Lack of system readiness
  • Unanticipated “opportunities”  quick fixes
  • Lack of provider education
  • Changes in leadership
  • Research funding not well suited
  • Clinical informatics expert – keeping expertise while on a research team*
conclusions49
Conclusions

Important Facilitators

  • Strong evidence-base
  • System readiness
  • Collaboration between researchers & quality improvement / clinical leaders
  • Flexible funding … and

most of all…

  • Clinical informatics expert
the end
The End

Thank You!

Bryan Volpp

Roxanne Rusch

Lynette Nilan

Dale Cannon

Alan Finkelstein

Katy Lysell

Ira Katz

Michael Mayo-Smith

VA Puget Sound Informatics

original cr tried to replicate elements in trials
Case Study #2A – Follow-up Clinical Reminder

Provider

Education

Routine

Screening

Provider

Patient

(+)

Prompt

Decision support

Handouts

Interview:

Assess

Severity

Original CR Tried to Replicate Elements in Trials
slide52
Follow-up Clinical Reminder

Version 1 (2001)

3 Local Focus Groups

Providers with variable needs

Most did not want to assess at all

Too much “help text” in CR

“Keep it simple”

Case Study #2A – Follow-up Clinical Reminder

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