MHA OverviewMHA OverviewVIREC VIREC

CyberseminarCyberseminarKathleen Lysell, PsyDKathleen Lysell, PsyD

Rick Owen, MDRick Owen, MD

November 20, 2007November 20, 2007

Session ObjectivesSession Objectives

Be familiar with the VHA Mental Health Be familiar with the VHA Mental Health Assistant software, including its use and Assistant software, including its use and applications in clinical care;applications in clinical care;

Understand how the software could be Understand how the software could be used in a research setting;used in a research setting;

Understand the process for creation of Understand the process for creation of national database of MHA assessment national database of MHA assessment data; anddata; and

Know about how the implementation of Know about how the implementation of the software was evaluatedthe software was evaluated

Mental Health Assistant Mental Health Assistant SoftwareSoftware

Mental Health AssistantMental Health Assistant

Graphical User Interface (GUI) for the Graphical User Interface (GUI) for the Mental Health testing package.Mental Health testing package.

Originally released 2002Originally released 2002 Provides secure computer environment Provides secure computer environment

for patient administered testingfor patient administered testing Only VistA application currently available Only VistA application currently available

that stores survey/self report information that stores survey/self report information as dataas data

2,800,000 assessments using MHA 2,800,000 assessments using MHA instruments completed in FY07instruments completed in FY07

Instruments Currently Instruments Currently Available in MHAAvailable in MHA

AIMSAIMS BSI18BSI18 MCMI2MCMI2 SCL9RSCL9R

ATQATQ BUSSBUSS MCMI3MCMI3 SDESSDES

AUDCAUDC CAGECAGE MISSMISS SF36SF36

AUDITAUDIT CESDCESD MMP2SMMP2S SMASTSMAST

AUIRAUIR CESD5CESD5 MMPI2MMPI2 STAISTAI

BAIBAI DOM80DOM80 PCLCPCLC VALDVALD

BDI2BDI2 DOMGDOMG PCLMPCLM WASWAS

BHSBHS HLOCHLOC PHQ9PHQ9 ZUNGZUNG

BPRSBPRS IEQIEQ RLOCRLOC

BSIBSI MBMDMBMD SAISAI

MHA3 New Features—Patch MHA3 New Features—Patch YS*5.01*85YS*5.01*85

MHA files completely restructured in VistAMHA files completely restructured in VistA Launch from CPRS Tools MenuLaunch from CPRS Tools Menu Pass progress note to CPRSPass progress note to CPRS New Instruments for MH Screening, New Instruments for MH Screening,

nursing, TBInursing, TBI With clinical reminders patch 6, all MHA With clinical reminders patch 6, all MHA

instruments will work with remindersinstruments will work with reminders Reminders will be able to use MH scales Reminders will be able to use MH scales

and individual responses in finding logicand individual responses in finding logic

Current System MH Test Current System MH Test FilesFiles

FILE #FILE # Name (Legacy)Name (Legacy)

601601 MH INSTRUMENT MH INSTRUMENT

601.2601.2 PSYCH PSYCH INSTRUMENT INSTRUMENT PATIENT PATIENT

601.3601.3 COPYRIGHT COPYRIGHT

HOLDERHOLDER 601.4601.4 INCOMPLETE PSYCH INCOMPLETE PSYCH

TEST PATIENT TEST PATIENT

601.6601.6 MH MULTIPLE MH MULTIPLE SCORING SCORING

MH Files New with Patch MH Files New with Patch YS*5.01*85YS*5.01*85

601.71601.71 MH TESTS AND MH TESTS AND SURVEYS SURVEYS

601.72601.72 MH QUESTIONS MH QUESTIONS

601.73601.73 MH INTRODUCTIONS MH INTRODUCTIONS

601.74I601.74I MH RESPONSE TYPES MH RESPONSE TYPES

601.75I601.75I MH CHOICES MH CHOICES

601.751601.751 MH CHOICETYPES MH CHOICETYPES

601.76601.76 MH INSTRUMENT MH INSTRUMENT CONTENT CONTENT

601.77I 601.77I MH BATTERIES MH BATTERIES

601.78601.78 MH BATTERY MH BATTERY CONTENTS CONTENTS

601.781601.781 MH BATTERY USERS MH BATTERY USERS

601.79601.79 MH SKIPPED MH SKIPPED QUESTIONS QUESTIONS

601.81601.81 MH SECTIONS MH SECTIONS

601.82601.82 MH RULES MH RULES

601.83 601.83 MH MH INSTRUMENTRULEINSTRUMENTRULES S

601.84601.84 MH MH ADMINISTRATIONS ADMINISTRATIONS

601.85601.85 MH ANSWERS MH ANSWERS

601.86I601.86I MH SCALEGROUPS MH SCALEGROUPS

601.87I601.87I MH SCALES MH SCALES

601.88601.88 MH DISPLAY MH DISPLAY

601.89601.89 MH MH CHOICEIDENTIFIERCHOICEIDENTIFIERS S

601.91601.91 MH SCORING KEYS MH SCORING KEYS

601.92601.92 MH RESULTS MH RESULTS

601.93601.93 MH REPORT MH REPORT

What does file structure What does file structure mean?mean?

Old structureOld structure, results only stored , results only stored as response string TTFT, report as response string TTFT, report recalculated on the fly every time recalculated on the fly every time test accessedtest accessed

Very difficult to research test results Very difficult to research test results on long testson long tests

All tests had to be coded into system All tests had to be coded into system using mumpsusing mumps

New File StructureNew File Structure Series of connected files that store entire Series of connected files that store entire

test administration datatest administration data Can evaluate scales, questions, raw or Can evaluate scales, questions, raw or

transformed scores rather than just transformed scores rather than just response stringsresponse strings

Greatly facilitates addition of new test Greatly facilitates addition of new test content—create instrument using Delphi content—create instrument using Delphi tool that translates it to mumps file tool that translates it to mumps file structurestructure

HL7 messaging used to create national HL7 messaging used to create national testing databasetesting database

New Instruments Added in New Instruments Added in MHA3MHA3

BOMC (Blessed Orientation Memory BOMC (Blessed Orientation Memory Concentration) TestConcentration) Test

Braden Skin Risk AssessmentBraden Skin Risk Assessment Morse Falls Risk ScaleMorse Falls Risk Scale PHQ-2PHQ-2 PC-PTSDPC-PTSD TBI 2TBI 2ndnd Level Evaluation Level Evaluation

Modified Instruments in Modified Instruments in MHA3MHA3

AUD-C: Invoke Skip Logic; add AUD-C: Invoke Skip Logic; add option “Never” as response to Item 1 option “Never” as response to Item 1 and “0” as response to Item 2and “0” as response to Item 2

PHQ-9: Add 10PHQ-9: Add 10thth question regarding question regarding impact of symptoms on overall impact of symptoms on overall functioningfunctioning

PHQ-9 Test Form in MHA3

MHA Research Example—AUDIT-MHA Research Example—AUDIT-CC

AUDIT-C response strings from alcohol use screens were extracted AUDIT-C response strings from alcohol use screens were extracted from VistA at a VA facility (n=65,484 AUDC response strings) for from VistA at a VA facility (n=65,484 AUDC response strings) for a 2 year period.a 2 year period.

90 combinations were identified for all AUDIT-C scores. 11 90 combinations were identified for all AUDIT-C scores. 11 response strings were identified that equal a score of 4 (see chart). response strings were identified that equal a score of 4 (see chart).

The most common drinking pattern representing a score of 4 was The most common drinking pattern representing a score of 4 was 400 (n= 11387, 17% of all combinations) - drinking 1-2 drinks daily, 400 (n= 11387, 17% of all combinations) - drinking 1-2 drinks daily, but never drinking > 6 drinks per occasion (binge drinking). The but never drinking > 6 drinks per occasion (binge drinking). The “400” response string accounted for 83% of all scores equaling 4.“400” response string accounted for 83% of all scores equaling 4.

There were 1249 (1.9% of all combinations) occurrences where the There were 1249 (1.9% of all combinations) occurrences where the score was 4 and the response string indicated binge drinking, as score was 4 and the response string indicated binge drinking, as represented by any response string with a 3represented by any response string with a 3rdrd digit of 1 or more (e.g. digit of 1 or more (e.g. 211,301,112). This pattern accounted for 9% of all scores equaling 211,301,112). This pattern accounted for 9% of all scores equaling 4.4.

AUD-C Response String FrequencyAUD-C Response String Frequency

459211

2004

FrequencyResponse String

1017310

6130

10103

37112

73220

108202

125121

11327400

508301

Total = 65,484 AUDIT-C screens

N with AUDIT-C score of 4 = 13,672

459211

2004

FrequencyResponse String

1017310

6130

10103

37112

73220

108202

125121

11327400

508301

Total = 65,484 AUDIT-C screens

N with AUDIT-C score of 4 = 13,672

Item checked equals 2 points

Item checked equals 1 point

Item checked equals 1 point

AUDIT-C Response AUDIT-C Response SamplesSamples

Enhancements in Clinical Enhancements in Clinical RemindersReminders

Clinical Reminders updated it’s code Clinical Reminders updated it’s code with patch PXRM*2.0*6, to work with patch PXRM*2.0*6, to work with new MH fileswith new MH files

Can work with MH scale within an Can work with MH scale within an instrument, or specific item within instrument, or specific item within an instrument as reminder findingan instrument as reminder finding

Reminders Using MH Item Reminders Using MH Item ResponseResponse

FINDING ITEM: AUDC//FINDING ITEM: AUDC// MH SCALE: 276//MH SCALE: 276//default of scales default of scales

associated with the instrumentassociated with the instrument CONDITION: I V("R",1)="Four or CONDITION: I V("R",1)="Four or

more times a week“ more times a week“ if the value of if the value of response to Item 1 is “four or more response to Item 1 is “four or more times a week”times a week”

AUD-C Response String in AUD-C Response String in Reminder LogicReminder Logic

Condition: I V("R",1)=“Four or more times Condition: I V("R",1)=“Four or more times a week”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 Found Text: Patient who might drink less than the safe limits.limits.

Using Reminders with MH Using Reminders with MH InstrumentsInstruments

Identify population, desired Identify population, desired frequency of measurement frequency of measurement

MH Performance Measures, FY08MH Performance Measures, FY08 PHQ-9, AUD-C, PC-PTSDPHQ-9, AUD-C, PC-PTSD

PC MH Integration AssessmentPC MH Integration Assessment PHQ-9, BAI, PCL, AUD-CPHQ-9, BAI, PCL, AUD-C

Testing DatabaseTesting Database

MH testing data stored in local VistA filesMH testing data stored in local VistA files MHA3 enhancements also create national testing MHA3 enhancements also create national testing

databasedatabase Test administrations transmitted using HL7 Test administrations transmitted using HL7

messagingmessaging Physically located in Pittsburgh, MH Informatics Physically located in Pittsburgh, MH Informatics

sectionsection Only includes test administration data, only data Only includes test administration data, only data

generated after MHA3 patch is installed in local generated after MHA3 patch is installed in local systemsystem

Establishing protocols for data usage with Austin Establishing protocols for data usage with Austin Corporate Data WarehouseCorporate Data Warehouse

Project Review, Lessons Project Review, Lessons LearnedLearned

Business CaseBusiness Case

MHA is a national software package; MHA is a national software package; the mental health package was one the mental health package was one of the early clinical packages in of the early clinical packages in VistAVistA

Significant cost savings/benefit Significant cost savings/benefit identified in automating identified in automating psychological testing processpsychological testing process

Improved clinical processes Improved clinical processes demonstrateddemonstrated

Expanding PresenceExpanding Presence Software historically limited to MH usage, but Software historically limited to MH usage, but

functionality valuable in other clinical settingsfunctionality valuable in other clinical settings Identified as tool that will store self report Identified as tool that will store self report

information as data rather than textinformation as data rather than text Useful in decision supportUseful in decision support Easy to add content in environment where new Easy to add content in environment where new

development is difficult to funddevelopment is difficult to fund Interact with clinical areas that have specific Interact with clinical areas that have specific

assessment by self report needs to broaden assessment by self report needs to broaden investmentinvestment

Integrate with CPRSIntegrate with CPRS Provide tools requested by program officesProvide tools requested by program offices

Approval ProcessApproval Process

Submit Project Requests to HISEBSubmit Project Requests to HISEB HISEB prioritizes all requests in portfolioHISEB prioritizes all requests in portfolio IDMC reviews priorities of 5 HISEB’sIDMC reviews priorities of 5 HISEB’s Funding based on budget from CongressFunding based on budget from Congress Executive priorities funded off the topExecutive priorities funded off the top Multi-year projects that are approved Multi-year projects that are approved

receive funding priority in subsequent receive funding priority in subsequent yearsyears

IssuesIssues Sites do not utilize full capacity of packageSites do not utilize full capacity of package Perception that it is only for psychological Perception that it is only for psychological

testingtesting Adequate resources to have computers Adequate resources to have computers

and space to use for patient administrationand space to use for patient administration Extended period of significant restriction Extended period of significant restriction

of development resourcesof development resources Uncertainty around VA software Uncertainty around VA software

development strategiesdevelopment strategies

Next StepsNext Steps

Clinical ContentClinical Content

Immediate goalImmediate goal Suicide prevention, TBI follow-up Suicide prevention, TBI follow-up

evaluation—high visibility, high evaluation—high visibility, high priority itemspriority items

Behavioral health—painBehavioral health—pain Mental health—recovery oriented Mental health—recovery oriented

assessment toolsassessment tools Geriatrics, HBPC assessment toolsGeriatrics, HBPC assessment tools

Authoring ToolAuthoring Tool

Use to build local instrumentsUse to build local instruments Delphi application—no programming Delphi application—no programming

experience necessaryexperience necessary Builds questionnaires with scoring Builds questionnaires with scoring

rules and reports templatesrules and reports templates

VUIDVUID

Veteran Unique IdentifierVeteran Unique Identifier Link to Enterprise Reference Link to Enterprise Reference

TerminologyTerminology Using SNOMED to code each item in Using SNOMED to code each item in

MH testsMH tests Provide Standardized Provide Standardized

coding/terminology associated with coding/terminology associated with elements of assessmentselements of assessments

ReferencesReferences Graham, A., et al. (2007). Effect of using different Graham, A., et al. (2007). Effect of using different

modes to administer the modes to administer the AUDIT-CAUDIT-C on on identification of hazardous drinking and identification of hazardous drinking and acquiescence to trial participation among injured acquiescence to trial participation among injured patients. patients. Alcohol and AlcoholismAlcohol and Alcoholism, 42, 423-429, 42, 423-429

Bush, K., et al. (1998). The AUDIT Alcohol Bush, K., et al. (1998). The AUDIT Alcohol Consumption Questions (AUDIT-C) An Effective Consumption Questions (AUDIT-C) An Effective Brief Screening Test for Problem Drinking. Brief Screening Test for Problem Drinking. Archives of Internal MedicineArchives of Internal Medicine, 158, 1789-1795., 158, 1789-1795.

Achtmeyer, C et al (2007). Using Mental Health Achtmeyer, C et al (2007). Using Mental Health Assistant AUDIT-C Data to Describe Patterns of Assistant AUDIT-C Data to Describe Patterns of Alcohol Use.  VeHU Conference, Orlando, FL. Alcohol Use.  VeHU Conference, Orlando, FL. http://vaww.vehu.med.va.gov/vehu/vehu2007/ppt/9903_LL.http://vaww.vehu.med.va.gov/vehu/vehu2007/ppt/9903_LL.pptppt