Embedding Recovery Outcomes Measurement in an EHR. Wes Williams, Ph.D. Director, Research & Development Mental Health Center of Denver

Transcription

1 Embedding Recovery Outcomes Measurement in an EHR Wes Williams, Ph.D. Director, Research & Development Mental Health Center of Denver

2 Private not-for-profit founded in 1989 Serving 15,400 adults, children, and families Services offered in over 35 locations throughout Denver Community-based collaborative services Culturally respectful services Enriching Lives and Minds by Focusing on Strengths and Recovery

3 Recovery People can, and do, recover from mental illness We provide appropriate and compassionate treatment for a mental health problem Individuals can get back to living a happy and productive life Consumers are involved in shaping their own recovery and given the chance to regain control of their lives

4 How? How do you know recovery is happening? How do you measure recovery?

5 Multiple Perspectives Recovery Needs Level Promoting Recovery in Organizations To what degree is recovery happening? Recovery Marker Inventory Consumer Recovery Measure

6 Recovery Needs Level (RNL) Evaluates Service Needs The RNL is designed to evaluate the level of services received by the consumer based on clinical variables Assessed on admission and every six months thereafter 15 items, including: GAF Hospitalizations Lethality Co-Occurring Substance Abuse Case Management Needs Levels of service determined by algorithm High Intensity Treatment Teams (12:1): eight to nine hours or more per month Community Treatment Teams (30:1): four hours or more per month Enhanced Outpatient (40:1): two hours per month Outpatient (80:1): monthly contact Psychiatry Only (n/a): quarterly contact

7 Consumer Recovery Measure (CRM) Consumer s Perspective 16 item self-report instrument Administered quarterly Summary of Recovery Hope Safety Active Growth Orientation Symptom Interference Social Networks Rasch Model Scored using Rasch model Stable weighing of items calculating total score

8 Recovery Markers Inventory (RMI) Staff Assessment of Recovery Supports Not recovery, but environmental markers supporting recovery Objective responses with detailed item anchors Assessed quarterly Seven Environmental Markers Housing Education Employment Participation in Services Symptom Mangement Active Growth Orientation Substance Abuse Rasch Model Stable item weighting for total score

9 Promoting Recovery in Organizations (PRO) Consumers View of Staff Stratified random sample Administered by consumer survey team Assessed annually How Do Specific Staff Promote Recovery? Case Managers Therapists Psychiatrists Front Desk Staff Residential Staff Vocational Staff Rasch Model Stable item weighting for score for each staff type by team Modeling completed 2011; FY 2012 is first year of reportable data

10 Implementation RNL development starts RNL released consumers served CRM released RMI released Reports available to clinical staff Recovery Profile PRO administered Awareness initiative New Recovery Profile Recovery Scattergram Fully embedded into workflow PRO revised

11 Slow Adoption Consumer participation lagged behind staff Original Recovery Profile Released 70% of eligible consumers completed CRM last quarter Jan-05 Aug-05 Mar-06 Oct-06 May-07 Dec-07 CRM Jul-08 Feb-09 RMI Consumer & Staff Training, Workflow Enhancements Completed Sep-09 Apr-10 Nov-10 Jun-11 Jan-12

12 Training Staff New staff already receive training Existing staff buy-in lagged Training team-by-team How to use: In supervision With consumers Consumers Biggest impact Consumer Survey Team (from PRO) Met consumers in waiting areas at each clinic

13 Issues with Initial Release Clunky reporting interface Separate sign-on to report server Overview reports didn t invite comparison Version 1.0 of Recovery Profile didn t emphasize most important data Data entry not built into workflow Hard to catch who needed to complete CRM Rasch modeling precluded immediate feedback Scoring algorithm required SQL lookup Initial design had lookup occurring day after data entry Less meaningful for consumers

14 Recovery Scattergram (CRM)

15 Recovery Scattergram (RMI)

16 Recovery Scattergram Explained Recovery Trends Plotted Against Starting Point Trends for consumers with at least three data points can be calculated Outliers are those progressing either faster or more slowly than expected Statistical Calculations R, an open-source statistical programming language, determines outliers Results are output to an SQL table uscript Bling Robert Edeker s SQL library is used to retrieve data jquery UI (a JavaScript/CSS library) handles accordion and glossy buttons Flot, a jquery plotting library, is used to create interactive plots RMI is used, receiving client ID from data-point when clicked

17 Not just a report: Clinicians can execute task by clicking on reminder Task List Prompts

18 Reminders on Appointments Front desk staff can give consumer survey

19 Reports Embedded in EHR Clinician encouraged to view Recovery Profile in the Session Prep module

20 Recovery Profile

21 CRM Details

22 RMI Details

23 Services & RNL

24 Recovery Profile (Content) Rasch Modeling Item responses are recorded in MIS, but test scores are calculated in data warehouse using SQL lookup Lookup tables are built where responses are weighted based on difficulty of item endorsement New DW-SQL INSERT technique allows for immediate lookup of Rasch score Clinical Use Conversation can occur on day of CRM data entry Workflow designed to follow clinical inquiry Graphs with subscales prompt clinical conversation about recovery Overall scores are statistically sound; breakdown is helpful for guiding understanding of recovery

25 Recovery Profile (JavaScript) Interactive Graphs Foster Inquiry Flot graphing library used to plot data in JavaScript Data series is an object, allowing for detailed tooltips to be created for each data point Series can be removed and added back to improve readability while still allowing comparison jquery Adds Easy Style jquery UI manages button gloss and compresses text by turning DIVs into accordions jquery can quickly add or remove CSS classes, striping tables and hiding text

26 jquery Accordion Add <div> to form using $tag jquery finds <div> and applies accordion

27 Future Directions Broader Population Child & Family Versions, Spanish Translations, ASL Videos Child and family resiliency instruments in year two of validation/revision cycle Spanish translations of the CRM and PRO ready for validation Case Reviews Treatment Planning Integration Consumer discussion on recovery progress is integrated into Case Review/Treatment Planning process Utilization Management Outlier Detection Use outliers in recovery trajectories in the same way we look for service hour outliers Peer Review Integrate PRO Use PRO results alongside documentation audits to set team goals More Sites Cross Site Validation of Instruments As more CMHCs adopt MHCD s recovery instruments, everyone will gain a better understanding of recovery

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