Depression CDSS Charles Kitzman, Barbary Baer, Sudha Poosa

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 2

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 3

Backdrop Higher rates for Suicide >50% 65 or older 4

Conditions leading to death - rates in Shasta County 5

County crisis stabilization 6

Rank by county 7

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 8

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 9

Screening Triggers 10

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 11

PHQ-9 Questionnaire 12

Depression CDSS flowchart 13

Depression CDSS Mindmap 14

System : Input  Demographics  Chief complaint  HPI (History of present illness)  Other illnesses  Medications  Life events 15

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 16

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 17

System : Output & Workflow 18

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 19

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 20

Q & A 21