September 16, 2008 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

carol.achtmeyer@va.gov

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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

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VistA Files

CPRS GUI and VistA

CPRS GUI

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

Health

Factors

Notes

Meds Labs MHA

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Notes (TIU) files

Mental Health Assistant (MHA) files

Health Factor files

CPRS interface displays and generates data stored in multiple VistA files

CPRS tabs

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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

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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

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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

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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

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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

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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

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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

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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!

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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

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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

PHQ9: Question #9

CR Patient Lists: MHA Findings to Identifying

Suicide Risk

15Screen Capture of the PHQ9 in CPRS. Question 9 is highlighted

CR Patient Lists: MHA Findings to Identifying

Suicide Risk

16Screen Capture of PHQ9 text in a progress note. Note text generated by Depression Follow Up Clinical Reminder

CR Patient Lists: MHA Findings to Identifying

Suicide Risk

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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?

CR Patient Lists: MHA Findings to Identifying

Suicide Risk

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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

CR Patient Lists: MHA Findings to Identifying

Suicide Risk

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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

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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)

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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

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Sequence: 10 Operation: REMOVE List Rule: SUICIDE ASSESS FINDINGS (FR)Rule Type: FINDING RULEReminder Term: SUICIDE ASSESS (RT)

Sequence: 5Operation: ADD PATIENTList Rule: PHQ9 Q9 (FR)Rule Type: FINDING RULEReminder Term: PHQ9 Q9 POS (RT)

Sequence: 15Operation: INSERT FINDINGList Rule: AUDC SCORES (FR)Rule Type: FINDING RULEReminder Term: VEHU AUDC SCORE (RT)Sequence: 20Operation: INSERT FINDINGList Rule: PHQ9 Scores (FR)Rule Type: FINDING RULE Reminder Term: VEHU PHQ9 Q9 POS (RT)

CPRS CR Patient Lists: Sequence

Example of the sequence used in clinical reminders patient list software

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Patient List results: ASCII Text

Patient Demographic Report*PATIENT^PHONE NUMBER^SSN^AUDIT-C SCORES,"FINDING NAME"^AUDIT-C SCORES,"VALUE"^PHQ9 SCORES,"FINDING NAME"^PHQ9 SCORES,"VALUE"^PHQ9SCORES,"R",9^\\PATIENT,ONE^(111)111-1111^000-00-1234^AUDC^11^PHQ9^21^Nearly every

day^\\PATIENT,TWO^(111)111-1112^000-00-1235^AUDC^7^PHQ9^17^Several days^\\PATIENT,THREE^(111)111-1113^000-00-1236^AUDC^1^PHQ9^22^Several days^\\PATIENT,FOUR^(111)111-1114^000-00-1233^AUDC^6^PHQ9^12^More than half the

days^\\

* Data is fictitious

The results display as ASCII text with delimiters. This text is copied and saved into a notepad file

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Creating Excel Table from ASCII text

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)111-1111^000-00-1234^AUDC^11^PHQ9^21^Nearly every day^\\PATIENT,TWO^(111)111-1112^000-00-1235^AUDC^7^PHQ9^17^Several days^\\PATIENT,THREE^(111)111-1113^000-00-1236^AUDC^1^PHQ9^22^Several days^\\PATIENT,FOUR^(111)111-1114^000-00-6234^AUDC^6^PHQ9^12^More than half the days^\\PATIENT,FIVE^(111)111-1115^000-00-1434^^^PHQ9^17^Several days^\\

ASCII text file

Excel display (after editing headings)

Use “Import External Data”

command” in Excel

PATIENT PHONE NUMBER SSN AUDIT-C Score PHQ9 Score Suicidal Thoughts

PATIENT,ONE (111)111-1111 000-00-1234 11 21 Nearly every dayPATIENT,TWO (111)111-1112 000-00-1235 7 17 Several daysPATIENT,THREE (111)111-1113 000-00-1236 1 22 Several daysPATIENT,FOUR (111)111-1114 000-00-6234 6 12 More than half daysPATIENT,FIVE (111)111-1115 000-00-1434 17 Several daysPATIENT,SIX (111)111-1116 000-00-1237 0 24 Several daysPATIENT,SEVEN (111)111-1117 000-00-1264 10 27 Nearly every dayPATIENT,EIGHT (111)111-1118 000-00-6234 8 17 Several days

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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

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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?

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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

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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

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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

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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

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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

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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

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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

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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

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Resources

General Patient List Training: VEHU 2006: Class 309h Playing by the Rules

Details of building Risk of Suicide list discussed here http://www.vehu.va.gov/vehu2008/ppt/9915_LL.p

pt Cyber series 2007: Clinical Reminders & Pt

Lists http://vaww.virec.research.va.gov/EducationReso

urces/Seminars/Informatics032007ra.ppt#267,20,Reminder Reports vs. Patient Lists