1. Identifying Patients at Risk of Suicide/Self-harm: A Demonstration of Clinical Reminder Patient Lists
Carol Achtmeyer MN, ARNP
VA SUD Quality Enhancement Research Initiative
VA Puget Sound Health Services Research & Development
September 16, 2008

2. Overview VistA files and CPRS
Approach to use of Clinical Reminder (CR) patient lists
Review example of risk of suicide/self harm
Strengths and limitations
Implications for research
Other query tools in VistA

3. CPRS GUI and VistA CPRS GUI VistA Files Notes Health Factors MHA Meds
Labs
Use of CPRS GUI generates data that is sent to and stored in VistA files. In turn the data in these VistA files is displayed in CPRS

4. Notes (TIU) files
Mental Health Assistant (MHA) files
Health Factor files
CPRS tabs
CPRS interface displays and generates data stored in multiple VistA files

5. Creating a Patient Cohort in VistA
National tools: No widely accessible tool available to extract nationwide data from VistA
Local tools:
Clinical Reminder Patient Lists
Fileman
Clinical Reminder Reports

6. CR Patient Lists: Overview
Introduced in 2006, but evolving in its use and capability
Uses the tools of clinical reminders software to build a cohort of patients meeting a defined criteria
Once list is built, can be auto-tasked or manually run at repeated intervals

7. CR Patient Lists: General Info
Faster than other options (CR reports or Fileman queries)
Can be used to extract certain data elements as well
Demographic Data – readily available, does not need to be programmed
Clinical data – program “insert data” command
Data can be updated on an existing list at any time
Output file is ASCII text with delimiters
Transfer to Excel, Access, Stata etc.
Built by Clinical Applications Coordinator (CAC) or Clinical Reminders person

8. CR Patient Lists: Potential Uses
Care Managers: track a group of patients on a monthly basis
Quality Managers: run a list to see which patients meet certain performance measures
Researchers:
Define a list of patients to determine what charts to review manually
Potential for use for data extraction as CPRS Patient List functionality evolves

9. Types of data in VistA to Create a CR Patient List (9/08)
Lab Tests
Health Factors
Mental Health Assistant (MHA) test results
Hospital/Clinic Location
Progress Note Titles
Medications
ICD9/CPT codes
Immunizations
Radiology procedures
Computer Findings used by clinical reminders
Tb test results
Vital Signs
Data displays
Limited or no display
Unknown
All items can be used to define list, but not all available to display data

10. Approach to Use of Patient Lists
Identify characteristics of the cohort
How are these characteristics represented in your system?
What information do you want to display in the report?
Must be computable data
Who is the person in your system that will build and run this report?
Data and security

11. Patient Lists and Mental Health Assistant (MHA) tests
MHA includes alcohol, depression and PTSD screening
More MHA tests added in January 2008
Multiple validated mental health screens
Can be accessed in CPRS
Using this new feature, a patient list may be based on:
Total score of a MHA screen
Response to an individual MHA screen question

12. CR Patient Lists: MHA Findings to Identifying Suicide Risk
A PHQ9 depression screen is required if initial PHQ2 screen is positive (Performance Measure)
PHQ9 Question #9 asks about thoughts of self harm
How can we monitor that patients who have reported thoughts of self harm on the PHQ9 have had a suicide assessment?
Answer: Patient Lists!

13. CR Patient Lists: MHA Findings to Identifying Suicide Risk
Example of how patient sample is defined (cohort definition)
Patients with thoughts of self harm as reported on the PHQ9
AND
No documentation of suicide assessment

14. CR Patient Lists: MHA Findings to Identifying Suicide Risk
PHQ9: Question #9
Over the past 2 weeks, how often have you been bothered
by any of the following problems: Thoughts that you would
be better off dead or hurting yourself in some way?
Not at all
Several days
More than half the days Positive responses
Nearly every day

15. CR Patient Lists: MHA Findings to Identifying Suicide Risk
Screen Capture of the PHQ9 in CPRS. Question 9 is highlighted

16. CR Patient Lists: MHA Findings to Identifying Suicide Risk
Screen Capture of PHQ9 text in a progress note. Note text generated by Depression Follow Up Clinical Reminder

17. CR Patient Lists: MHA Findings to Identifying Suicide Risk
Target list is: patients who have reported thoughts of self harm on PHQ9, but still need a suicide risk assessment
In the Sample Definition: Patients with documentation of suicide risk assessment are excluded
How do we know if a patient had a suicide risk assessment or not?
i.e. what computable data is available that I can use to represent the concept of suicide risk assessment?

18. CR Patient Lists: MHA Findings to Identifying Suicide Risk
Review of clinic process to assess suicide risk showed two things we could use for the patient list query:
Health Factors: linked to suicide risk assessment in depression/PTSD follow-up CR’s
A Progress Note Title: “Mental Health Triage Evaluation Note” used by MH staff included a suicide risk assessment template

19. Health Factor: Suicide Risk Assessment Completed
When this choice is checked, a data tag called a Health Factor is sent to VistA
This health factor can be used to show that a suicide risk assessment was done

20. Patient Sample and Report
Sample definition:
Patients who have reported thoughts of self harm but have not had suicide assessment
List of information to display for each patient on this list:
Name, telephone number and SSN
PHQ 9 total score (MHA PHQ9)
PHQ 9 question 9 response (MHA PHQ9)
Alcohol use screen score (MHA AUDC)

21. Demographic Data Available in CPRS CR Patient Lists (9/08)
CURRENT ADDRESS
PHONE NUMBER
APPOINTMENT DATE
CLINIC
SSN
DATE OF BIRTH
AGE
SEX
DATE OF DEATH
REMARKS
HISTORIC RACE
RELIGION
MARITAL STATUS
ETHNICITY
RACE
PRIMARY ELGIBILITY CODE
PERIOD OF SERVICE
SERVICE CONNECTED
VETERAN
TYPE
ELIGIBILITY STATUS
CURRENT MEANS TEST

22. CPRS CR Patient Lists: Sequence
Operation: ADD PATIENT
List Rule: PHQ9 Q9 (FR)
Rule Type: FINDING RULE
Reminder Term: PHQ9 Q9 POS (RT)
Example of the sequence used in clinical reminders patient list software
Sequence: 10
Operation: REMOVE
List Rule: SUICIDE ASSESS FINDINGS (FR)
Rule Type: FINDING RULE
Reminder Term: SUICIDE ASSESS (RT)
Sequence: 15
Operation: INSERT FINDING
List Rule: AUDC SCORES (FR)
Rule Type: FINDING RULE
Reminder Term: VEHU AUDC SCORE (RT)
Sequence: 20
Operation: INSERT FINDING
List Rule: PHQ9 Scores (FR)
Rule Type: FINDING RULE
Reminder Term: VEHU PHQ9 Q9 POS (RT)

23. Patient List results: ASCII Text
The results display as ASCII text with delimiters. This text is copied and saved into a notepad file
Patient Demographic Report*
PATIENT^PHONE NUMBER^SSN^AUDIT-C SCORES,"FINDING NAME"^AUDIT-C SCORES,
"VALUE"^PHQ9 SCORES,"FINDING NAME"^PHQ9 SCORES,"VALUE"^PHQ9
SCORES,"R",9^\\
PATIENT,ONE^(111) ^ ^AUDC^11^PHQ9^21^Nearly every day^\\
PATIENT,TWO^(111) ^ ^AUDC^7^PHQ9^17^Several days^\\
PATIENT,THREE^(111) ^ ^AUDC^1^PHQ9^22^Several days^\\
PATIENT,FOUR^(111) ^ ^AUDC^6^PHQ9^12^More than half the days^\\
* Data is fictitious

24. Creating Excel Table from ASCII text
ASCII text file
PATIENT^PHONE NUMBER^SSN^AUDIT-C SCORES,"FINDING NAME"^AUDIT-C SCORES,
"VALUE"^PHQ9 SCORES,"FINDING NAME"^PHQ9 SCORES,"VALUE"^PHQ9 SCORES,"R",9^\\
PATIENT,ONE^(111) ^ ^AUDC^11^PHQ9^21^Nearly every day^\\
PATIENT,TWO^(111) ^ ^AUDC^7^PHQ9^17^Several days^\\
PATIENT,THREE^(111) ^ ^AUDC^1^PHQ9^22^Several days^\\
PATIENT,FOUR^(111) ^ ^AUDC^6^PHQ9^12^More than half the days^\\
PATIENT,FIVE^(111) ^ ^^^PHQ9^17^Several days^\\
Use “Import External Data” command” in Excel
Excel display (after editing headings)

25. CPRS CR Patient Lists: Identifying Suicide Risk
How might this list be used?
Facilitates timely follow up of patients who need suicide risk assessment
Additional information of
level of depression (PHQ9 score),
frequency of suicidal thoughts (Q9 PHQ9)
possible heavy alcohol use (AUDIT-C score)
allows triage of the list to assess pts who may need urgent evaluation
Can re-run list regularly – follow if patients are getting assessed. If clinic processes changed, can use list to determine if change successful

26. CR Patient Lists: Process Issues
Who is the audience for this list?
Essential to have identified process in place to use the data
Who will run the list?
How often will list be run?
Who is responsible for following up the information?
Data management expertise?
How will data be stored securely?

27. CR Patient Lists: Technical Issues
Not all CR finding items can be used to display data, must be “csub” findings
MH test dates not yet available in data display
A Clinical Applications Coordinator (CAC) will need to be involved on an ongoing basis.
Patient Lists generated from CR reports can also display data – requires some additional steps

28. CR Patient List: Limitations
No date associated with many of the findings, so can only get data in a certain time range
Can only display the most recent finding for a patient, not multiple findings
Due to technical issues, not all data fields in a particular file may be available to insert in to a report

29. Can CR Patient Lists generate data for a research data base?
Patient list tools useful for generating a list of patients meeting criteria defined by the available fields.
Could identify patients for manual chart review
But, as of today, with the limitations of Clinical Reminders patient lists, it is probably not ready to pull data for research data base purposes

30. Uses of CR Patient Lists
For research: Consider using patient lists to define or follow a sample.
For care managers/QI: excellent tool to quickly identify a group, follow patient cohort, or give “snapshot” of clinical data

31. CR Patient lists: Changes (? release date)
Dates will be added to MHA tests and other clinical findings
Will include tools that allow the exchange of patient list queries or components between facilities
Additional csub data will be available

32. Other Tools to query VistA: Fileman
Pros:
Creates lists of patients
Flexible, allows complex queries
Reports can include clinical data
Cons
Steep learning curve
Must be familiar with VistA file structure
Comparatively slow

33. Other tools to Query VistA: Clinical Reminder Reports
Pros
Able to identify a cohort
Able to apply complex logic to define the cohort
Used for QI purposes
Cons
Must convert “due” and “applicable” to numerator and denominator
Faster than fileman, but patient lists are faster than CR reports
Does not display clinical data

34. Summary
CR Patient list functionality can be used to create patient cohorts that can be followed over time, as well as display data.
There are some limitations to this tool that may limit its use for researchers, but there may be multiple applications for care managers and QI staff.
Fileman and clinical reminder reports are also available, but patient list may be preferable due to it’s speed, function and usability

35. Resources General Patient List Training:
VEHU 2006: Class 309h Playing by the Rules
Details of building Risk of Suicide list discussed here
Cyber series 2007: Clinical Reminders & Pt Lists
Reports vs. Patient Lists