1. Development of a Primary Care Behavioral Health (PCBH) Electronic Health Record (EHR) Module to Improve Practice, Documentation, and Program Evaluation Anne C. Dobmeyer, PhD, ABPP, Chief Psychologist, PCBH Directorate, Deployment Health Clinical Center Jennifer L. Bell, MD, Associate Director, PCBH Directorate, Deployment Health Clinical Center Christopher L. Hunter, PhD, ABPP, DoD Program Manager for Behavioral Health in Primary Care Collaborative Family Healthcare Association 17 th Annual Conference October 15-17, 2015 Portland, Oregon U.S.A. Session # G3a October 16, 2015

2. Faculty Disclosure The presenters of this session have NOT had any relevant financial relationships during the past 12 months.

3. Learning Objectives At the conclusion of this session, the participant will be able to: Describe how using an enhanced EHR module specific to PCBH may improve clinical practice Identify the benefits of increased standardization in PCBH documentation made possible through use of a PCBH EHR module Discuss ways in which development of a PCBH EHR module may aid program evaluation in large medical systems

4. Bibliography / References 1.Dobmeyer, A. C., Goodie, J. L., & Hunter, C. L. (2014). Health care provider and systems interventions promoting health behavior change. In K. A. Riekert, J. K. Ockene, & L. Pbert (Eds.), The Handbook of Health Behavior Change (4 th ed.). New York: Springer (pp. 417-436). 2.Hunter, C. L., Goodie, J. L., Dobmeyer, A. C., & Dorrance, K. A. (2014). Tipping points in the Department of Defense’s experience with psychologists in primary care. American Psychologist, 69 (4), 388-398. 3.Hunter, C. L., & Goodie, J. L. (2010). Operational and clinical components for integrated-collaborative behavioral health care in the patient centered medical home. Families, Systems, & Health, 28, 308-321. 4.Ray-Sannerud, B. N., Dolan, D. C., Morrow, C. E., Corso, K. A., Kanzler, K. E., Corso, M. L., & Bryan, C. J. (2012). Longitudinal outcomes after brief behavioral health intervention in an integrated primary care clinic. Families, Systems, & Health, 30, 60-71. 5.Reitz, R., Common, K., Fifield, P., & Stiasny, E. (2012). Collaboration in the presence of an electronic health record. Families, Systems, and Health, 30, 72- 80.

5. Learning Assessment A learning assessment is required for CE credit. A question and answer period will be conducted at the end of this presentation.

6. Disclaimer The views expressed are those of the authors and do not reflect the official policy of the Department of Defense (DoD), the United States Public Health Service (USPHS) or the U.S. Government.

7. Acknowledgements The authors would like to acknowledge the following individuals who were instrumental in the initial development of the DoD EHR PCBH module: Meghan Corso, PsyD Jay Earles, PsyD Charles Milliken, MD Joshua Morganstein, MD Matthew Nielsen, PhD

8. Overview Context: PCBH in the Department of Defense (DoD) Rationale for EHR PCBH module Development process and product Training Impact on program evaluation Current/future directions ‒ Quarterly improvements/updates ‒ Enhancements to primary care provider (PCP) EHR module

9. Context: PCBH in the DoD DoD Military Health System (MHS) serves 3.3 million beneficiaries in military facility primary care (PC) clinics¹ DoD policy requires all PC clinics with > 3,000 enrollees have a full-time behavioral health consultant (BHC) using PCBH model¹ ‒ 313 BHCs; 313 clinics BHCs document care in the DoD EHR ‒ Shared medical record (no separate behavioral health chart)² ‒ Documentation occurs during appointment ‒ Variability in format and location of BHC documentation ‒ Very limited ability to extract data beyond basics (demographics, visit type and length, procedure coding, diagnosis) ¹Hunter, C. L., Goodie, J. L., Dobmeyer, A. C., & Dorrance, K. A. (2014). Tipping points in the Department of Defense’s experience with psychologists in primary care. American Psychologist, 69 (4), 388-398. ²Hunter, C. L., & Goodie, J. L. (2010). Operational and clinical components for integrated-collaborative behavioral health care in the patient centered medical home. Families, Systems, & Health, 28, 308-321.

10. Rationale for EHR PCBH Module Improve documentation ‒ Quality ‒ Efficiency ‒ Standardization Improve clinical practice through prompts/reminders during clinical practice¹ ‒ Assessment prompts ‒ Evidence-based intervention options ‒ Links to assessment instruments and patient handouts ‒ Options for recommendations to PCPs Improve program evaluation capabilities ‒ “Mineable” data for key variables ¹ Dobmeyer, A. C., Goodie, J. L., & Hunter, C. L. (2014). Health care provider and systems interventions promoting health behavior change. In K. A. Riekert, J. K. Ockene, & L. Pbert (Eds.), The Handbook of Health Behavior Change (4 th ed.). New York: Springer (pp. 417-436).

11. Development Process Multidisciplinary team ‒ PCBH program managers for DoD and all Service branches ‒ Multidisciplinary team of PCBH subject matter experts (SMEs) ‒ Technical assistance provided through contract support to Defense Health Headquarters Workgroup meetings over time ‒ Initial form development occurred over 3-day meeting ‒ Monthly telephonic meetings for first year ‒ Quarterly telephonic meetings thereafter Consensus required ‒ Inclusion of new content (or revisions) must have concurrence from all Service program managers Quality control and improvement ‒ Beta testing periods ‒ Ongoing feedback from BHCs in the field

12. Product Overview Admin Tab ̶ Medical, family, social history ̶ Health behaviors (alcohol, tobacco, caffeine, exercise) ̶ Behavioral Health Measure-20 (BHM-20) Screening Tab ‒ PHQ-9, PCL-C, GAD-7, AUDIT-C, PEG-3, etc. Problem-Specific Tabs ‒ Depression, Anxiety, Sleep, Obesity, Pain, etc. ‒ Prompts assist BHC in assessing and documenting key areas Mental Status Exam (MSE) Tab

13. Admin Tab

14. Screening Tab: PEG

15. Pain Tab: HPI

16. Pain Tab: Intervention

17. Pain Tab: Recommendations

18. MSE Tab: P4 Suicide Assessment

19. Training Initial training ‒ 6 hour, hands-on training during the DoD IBHC training course, or ‒ Site visit from EHR trainers Supplemental training ‒ Documentation training package (webinar, written guidelines/examples) ‒ Individual training from a DoD BHC trainer (during IBHC training site visit)

20. Impact on Program Evaluation Prior to EHR PCBH module, program evaluation was possible¹ but challenging ‒ Required separate system for maintaining relevant data ‒ Required hand-entering of data ‒ Was limited to small number of clinics with motivated staff ‒ Did not provide broad look at multiple variables across many clinics ¹Ray-Sannerud, B. N., Dolan, D. C., Morrow, C. E., Corso, K. A., Kanzler, K. E., Corso, M. L., & Bryan, C. J. (2012). Longitudinal outcomes after brief behavioral health intervention in an integrated primary care clinic. Families, Systems, & Health, 30, 60-71.

21. Impact on Program Evaluation (cont’d) With EHR PCBH module, evaluation capabilities are expanded ‒ Data available from all clinics across large medical system ‒ No separate data entry required ‒ Program managers can access data more easily ‒ Chart reviews easier ‒ Information is found in consistent locations ‒ Consistent terminology used ‒ More relevant process and outcome variables available

22. Impact on Program Evaluation (cont’d) Patient outcome variables ‒ Scores over time on variety of assessment instruments ‒ Global functioning (BHM-20) ‒ Symptom specific (PHQ-9, GAD-7, PCL-C, etc.) ‒ Suicide risk variables BHC practice/process variables ‒ Number of appointments per episode of care ‒ Percent of encounters in which required assessment given ‒ Percent of encounters in which feedback given to PCP ‒ Percent of new patient appointments in which handout given as part of informed consent process

23. Current/Future Directions Quarterly improvements/updates ‒ Pediatric assessment measures ‒ Copy forward function for assessment results ‒ Links to additional patient education materials ‒ Guidance for BHC action based on suicide risk level Enhancements to primary care provider (PCP) EHR module ‒ Data-minable documentation of patient referral to PCBH ‒ PCBH related clinical clues/reminders for PCMs ‒ Addition of mandated PTSD screen

24. Q & A/Summary How might using an enhanced EHR module specific to PCBH improve clinical practice? What are some benefits of increased standardization in documentation made possible through use of a PCBH EHR module? How might use of a PCBH EHR module aid program evaluation in large medical systems?

25. Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!