1. MHA Overview VIREC Cyberseminar Kathleen Lysell, PsyD Rick Owen, MD November 20, 2007

2. Session Objectives Be familiar with the VHA Mental Health Assistant software, including its use and applications in clinical care; Be familiar with the VHA Mental Health Assistant software, including its use and applications in clinical care; Understand how the software could be used in a research setting; Understand how the software could be used in a research setting; Understand the process for creation of national database of MHA assessment data; and Understand the process for creation of national database of MHA assessment data; and Know about how the implementation of the software was evaluated Know about how the implementation of the software was evaluated

3. Mental Health Assistant Software

4. Mental Health Assistant Graphical User Interface (GUI) for the Mental Health testing package. Graphical User Interface (GUI) for the Mental Health testing package. Originally released 2002 Originally released 2002 Provides secure computer environment for patient administered testing Provides secure computer environment for patient administered testing Only VistA application currently available that stores survey/self report information as data Only VistA application currently available that stores survey/self report information as data 2,800,000 assessments using MHA instruments completed in FY07 2,800,000 assessments using MHA instruments completed in FY07

5. Instruments Currently Available in MHA AIMSBSI18MCMI2SCL9R ATQBUSSMCMI3SDES AUDCCAGEMISSSF36 AUDITCESDMMP2SSMAST AUIRCESD5MMPI2STAI BAIDOM80PCLCVALD BDI2DOMGPCLMWAS BHSHLOCPHQ9ZUNG BPRSIEQRLOC BSIMBMDSAI

6. MHA3 New Features—Patch YS*5.01*85 MHA files completely restructured in VistA MHA files completely restructured in VistA Launch from CPRS Tools Menu Launch from CPRS Tools Menu Pass progress note to CPRS Pass progress note to CPRS New Instruments for MH Screening, nursing, TBI New Instruments for MH Screening, nursing, TBI With clinical reminders patch 6, all MHA instruments will work with reminders With clinical reminders patch 6, all MHA instruments will work with reminders Reminders will be able to use MH scales and individual responses in finding logic Reminders will be able to use MH scales and individual responses in finding logic

7. Current System MH Test Files FILE # Name (Legacy) 601 MH INSTRUMENT 601.2 PSYCH INSTRUMENT PATIENT 601.3 COPYRIGHT HOLDER 601.4 INCOMPLETE PSYCH TEST PATIENT 601.6 MH MULTIPLE SCORING

8. MH Files New with Patch YS*5.01*85 601.71 MH TESTS AND SURVEYS 601.72 MH QUESTIONS 601.73 MH INTRODUCTIONS 601.74I MH RESPONSE TYPES 601.75I MH CHOICES 601.751 MH CHOICETYPES 601.76 MH INSTRUMENT CONTENT 601.77I MH BATTERIES 601.78 MH BATTERY CONTENTS 601.781 MH BATTERY USERS 601.79 MH SKIPPED QUESTIONS 601.81 MH SECTIONS 601.82 MH RULES 601.83 MH INSTRUMENTRULES 601.84 MH ADMINISTRATIONS 601.85 MH ANSWERS 601.86I MH SCALEGROUPS 601.87I MH SCALES 601.88 MH DISPLAY 601.89 MH CHOICEIDENTIFIERS 601.91 MH SCORING KEYS 601.92 MH RESULTS 601.93 MH REPORT

9. What does file structure mean? Old structure, results only stored as response string TTFT, report recalculated on the fly every time test accessed Old structure, results only stored as response string TTFT, report recalculated on the fly every time test accessed Very difficult to research test results on long tests Very difficult to research test results on long tests All tests had to be coded into system using mumps All tests had to be coded into system using mumps

10. New File Structure Series of connected files that store entire test administration data Series of connected files that store entire test administration data Can evaluate scales, questions, raw or transformed scores rather than just response strings Can evaluate scales, questions, raw or transformed scores rather than just response strings Greatly facilitates addition of new test content—create instrument using Delphi tool that translates it to mumps file structure Greatly facilitates addition of new test content—create instrument using Delphi tool that translates it to mumps file structure HL7 messaging used to create national testing database HL7 messaging used to create national testing database

11. New Instruments Added in MHA3 BOMC (Blessed Orientation Memory Concentration) Test BOMC (Blessed Orientation Memory Concentration) Test Braden Skin Risk Assessment Braden Skin Risk Assessment Morse Falls Risk Scale Morse Falls Risk Scale PHQ-2 PHQ-2 PC-PTSD PC-PTSD TBI 2 nd Level Evaluation TBI 2 nd Level Evaluation

12. Modified Instruments in MHA3 AUD-C: Invoke Skip Logic; add option “Never” as response to Item 1 and “0” as response to Item 2 AUD-C: Invoke Skip Logic; add option “Never” as response to Item 1 and “0” as response to Item 2 PHQ-9: Add 10 th question regarding impact of symptoms on overall functioning PHQ-9: Add 10 th question regarding impact of symptoms on overall functioning

16. PHQ-9 Test Form in MHA3

20. MHA Research Example — AUDIT-C  AUDIT-C response strings from alcohol use screens were extracted from VistA at a VA facility (n=65,484 AUDC response strings) for a 2 year period.  90 combinations were identified for all AUDIT-C scores. 11 response strings were identified that equal a score of 4 (see chart).  The most common drinking pattern representing a score of 4 was 400 (n= 11387, 17% of all combinations) - drinking 1-2 drinks daily, but never drinking > 6 drinks per occasion (binge drinking). The “ 400 ” response string accounted for 83% of all scores equaling 4.  There were 1249 (1.9% of all combinations) occurrences where the score was 4 and the response string indicated binge drinking, as represented by any response string with a 3 rd digit of 1 or more (e.g. 211,301,112). This pattern accounted for 9% of all scores equaling 4.

21. AUD-C Response String Frequency

22. Item checked equals 2 points Item checked equals 1 point AUDIT-C Response Samples

23. Enhancements in Clinical Reminders Clinical Reminders updated it’s code with patch PXRM*2.0*6, to work with new MH files Clinical Reminders updated it’s code with patch PXRM*2.0*6, to work with new MH files Can work with MH scale within an instrument, or specific item within an instrument as reminder finding Can work with MH scale within an instrument, or specific item within an instrument as reminder finding

24. Reminders Using MH Item Response FINDING ITEM: AUDC// FINDING ITEM: AUDC// MH SCALE: 276//default of scales associated with the instrument MH SCALE: 276//default of scales associated with the instrument CONDITION: I V("R",1)="Four or more times a week“ if the value of response to Item 1 is “four or more times a week” CONDITION: I V("R",1)="Four or more times a week“ if the value of response to Item 1 is “four or more times a week”

25. AUD-C Response String in Reminder Logic Condition: I V("R",1)=“Four or more times a week” Condition: I V("R",1)=“Four or more times a week” Condition: I V("R",2)="3 or 4" Condition: I V("R",2)="3 or 4" Condition: I V("R",3)="Never" Condition: I V("R",3)="Never" Function String: FI(2)&FI(3)&FI(4) Function String: FI(2)&FI(3)&FI(4) Expanded Function String: Expanded Function String: FI(AUDC,R,1)&FI(AUDC,R,2)&FI(AUDC,R,3) FI(AUDC,R,1)&FI(AUDC,R,2)&FI(AUDC,R,3) Found Text: Patient who might drink less than the safe limits. Found Text: Patient who might drink less than the safe limits.

27. Using Reminders with MH Instruments Identify population, desired frequency of measurement Identify population, desired frequency of measurement MH Performance Measures, FY08 MH Performance Measures, FY08 PHQ-9, AUD-C, PC-PTSD PHQ-9, AUD-C, PC-PTSD PC MH Integration Assessment PC MH Integration Assessment PHQ-9, BAI, PCL, AUD-C PHQ-9, BAI, PCL, AUD-C

28. Testing Database MH testing data stored in local VistA files MH testing data stored in local VistA files MHA3 enhancements also create national testing database MHA3 enhancements also create national testing database Test administrations transmitted using HL7 messaging Test administrations transmitted using HL7 messaging Physically located in Pittsburgh, MH Informatics section Physically located in Pittsburgh, MH Informatics section Only includes test administration data, only data generated after MHA3 patch is installed in local system Only includes test administration data, only data generated after MHA3 patch is installed in local system Establishing protocols for data usage with Austin Corporate Data Warehouse Establishing protocols for data usage with Austin Corporate Data Warehouse

29. Project Review, Lessons Learned

30. Business Case MHA is a national software package; the mental health package was one of the early clinical packages in VistA MHA is a national software package; the mental health package was one of the early clinical packages in VistA Significant cost savings/benefit identified in automating psychological testing process Significant cost savings/benefit identified in automating psychological testing process Improved clinical processes demonstrated Improved clinical processes demonstrated

31. Expanding Presence Software historically limited to MH usage, but functionality valuable in other clinical settings Software historically limited to MH usage, but functionality valuable in other clinical settings Identified as tool that will store self report information as data rather than text Identified as tool that will store self report information as data rather than text Useful in decision support Useful in decision support Easy to add content in environment where new development is difficult to fund Easy to add content in environment where new development is difficult to fund Interact with clinical areas that have specific assessment by self report needs to broaden investment Interact with clinical areas that have specific assessment by self report needs to broaden investment Integrate with CPRS Integrate with CPRS Provide tools requested by program offices Provide tools requested by program offices

32. Approval Process Submit Project Requests to HISEB Submit Project Requests to HISEB HISEB prioritizes all requests in portfolio HISEB prioritizes all requests in portfolio IDMC reviews priorities of 5 HISEB’s IDMC reviews priorities of 5 HISEB’s Funding based on budget from Congress Funding based on budget from Congress Executive priorities funded off the top Executive priorities funded off the top Multi-year projects that are approved receive funding priority in subsequent years Multi-year projects that are approved receive funding priority in subsequent years

33. Issues Sites do not utilize full capacity of package Sites do not utilize full capacity of package Perception that it is only for psychological testing Perception that it is only for psychological testing Adequate resources to have computers and space to use for patient administration Adequate resources to have computers and space to use for patient administration Extended period of significant restriction of development resources Extended period of significant restriction of development resources Uncertainty around VA software development strategies Uncertainty around VA software development strategies

34. Next Steps

35. Clinical Content Immediate goal Immediate goal Suicide prevention, TBI follow-up evaluation— high visibility, high priority items Suicide prevention, TBI follow-up evaluation— high visibility, high priority items Behavioral health—pain Behavioral health—pain Mental health—recovery oriented assessment tools Mental health—recovery oriented assessment tools Geriatrics, HBPC assessment tools Geriatrics, HBPC assessment tools

36. Authoring Tool Use to build local instruments Use to build local instruments Delphi application—no programming experience necessary Delphi application—no programming experience necessary Builds questionnaires with scoring rules and reports templates Builds questionnaires with scoring rules and reports templates

39. VUID Veteran Unique Identifier Veteran Unique Identifier Link to Enterprise Reference Terminology Link to Enterprise Reference Terminology Using SNOMED to code each item in MH tests Using SNOMED to code each item in MH tests Provide Standardized coding/terminology associated with elements of assessments Provide Standardized coding/terminology associated with elements of assessments

40. References Graham, A., et al. (2007). Effect of using different modes to administer the AUDIT-C on identification of hazardous drinking and acquiescence to trial participation among injured patients. Alcohol and Alcoholism, 42, 423-429 Graham, A., et al. (2007). Effect of using different modes to administer the AUDIT-C on identification of hazardous drinking and acquiescence to trial participation among injured patients. Alcohol and Alcoholism, 42, 423-429 Bush, K., et al. (1998). The AUDIT Alcohol Consumption Questions (AUDIT-C) An Effective Brief Screening Test for Problem Drinking. Archives of Internal Medicine, 158, 1789-1795. Bush, K., et al. (1998). The AUDIT Alcohol Consumption Questions (AUDIT-C) An Effective Brief Screening Test for Problem Drinking. Archives of Internal Medicine, 158, 1789-1795. Achtmeyer, C et al (2007). Using Mental Health Assistant AUDIT-C Data to Describe Patterns of Alcohol Use. VeHU Conference, Orlando, FL. http://vaww.vehu.med.va.gov/vehu/vehu2007/ppt/9903_LL.ppt Achtmeyer, C et al (2007). Using Mental Health Assistant AUDIT-C Data to Describe Patterns of Alcohol Use. VeHU Conference, Orlando, FL. http://vaww.vehu.med.va.gov/vehu/vehu2007/ppt/9903_LL.ppt http://vaww.vehu.med.va.gov/vehu/vehu2007/ppt/9903_LL.ppt