Tag: Evidence based practice

Case Management with Email Messaging

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Many of our customers include Case Management as part of the mix of services provided to clients. Among the seriously mentally ill (SMI) population, Case Management has become an essential service helping individuals gain the most from the services they receive. Helping the client take their medication as prescribed, assessing their current symptom status, intervening to alter treatment rapidly if a crisis is looming are all functions that Case Managers provide. These services are provided both in-person and by telephone.

A new study published in The Journal of General Internal Medicine suggests that email contact with a trained psychiatric nurse can dramatically improve the outcome of medication treatment for depression by internal medicine practices. Reported in Healthcare IT News on March 17, the study was a follow-up to a similar study using telephone contact with patients who had newly been started on antidepressant medication. According to the report, the email messaging was even more effective than a telephone call in improving the benefit of the medication.

The study utilized 208 members of Group Health, a consumer-governed, nonprofit, integrated healthcare organization that coordinates care and coverage for 600,000 individuals in Washington state and Idaho. The Group Health Research Institute (GHRI) was the responsible research organization. GHRI  is a non-proprietary, public-domain research institution within Group Health.

The Group Health plan includes a patient portal that has access into the organization’s electronic health record. According to the abstract of the article, the Intervention consisted of:

 Three online care management contacts with a trained psychiatric nurse. Each contact included a structured assessment (severity of depression, medication adherence, side effects), algorithm-based feedback to the patient and treating physician, and as-needed facilitation of follow-up care. All communication occurred through secure, asynchronous messages within an electronic medical record.

This study was motivated by poor improvement outcomes reported nationally for depressed individuals treated by their primary care providers with antidepressant medication. The goal of the entire research project is to determine if use of an organized plan of treatment including evidence-based follow-up services would result in greater effectiveness of medical therapy.

A significant movement is developing within the U.S. to improve outcomes of our healthcare system by providing services in non-traditional ways. The Connected Healthmovement seeks to improve healthcare services and outcomes by use of technology to remotely monitor and provide services. Partners Healthcare Center for Connected Health has been a pioneer in this effort. Their web site states the goal in this fashion:

Changing Healthcare Delivery

We are engaging patients, providers and the connected health community to deliver quality care outside of traditional medical settings. Telehealth, remote care and disease management initiatives reflect the opportunities for technology-enabled care programs.

What potentials do you see for the use of electronic methodologies like secure email communication with clients within your organization? Are you already engaged in such endeavors? What do you see as the obstacles to such care? What are the potential benefits to your clients? How do we get from here to there?

Please share your experiences, concerns and other comments below.

Implementing Evidence Based Practices

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Last week I attended the semiannual member meeting of the Software and Technology Vendor Association (SATVA), the trade association I have mentioned in the past. At lunch, I sat at a table with Don Hevey, the President/CEO of MHCA, described as “an alliance of select organizations that provide behavioral health services.” Their members are some of the largest community mental health centers in the country. We were talking about accountability and evidence based practices and Don mentioned a statistic from the American Medical Informatics Association and quoted in the American Psychological Association’s Monitor on Psychology

that it takes as long as 17 years for research findings to enter medical or mental health practice, and even then, only a fraction makes it in.

One of the others at the table (MHCA chair Tony Kopera, Ph.D.) indicated that part of the problem in mental health is that treatment protocols are often designed for and tested on those with a unitary diagnosis and relatively stable lives. This does not match the real world, community behavioral health center situation where many of the seriously mentally ill carry multiple diagnoses and may bounce from group home to the street to jail to hospital and back again.

The American Psychological Association has begun a science/practice collaboration for the purpose of creating treatment guidelines. Since the U.S. healthcare system has begun a significant focus on accountability, “providers need to show insurers and policymakers that their treatments provide good outcomes for patients” according to Katherine Nordal, Ph.D., executive director of APA’s Practice Directorate.

A treatment guideline won’t be a one-size-fits-all cookbook approach, she emphasized. Instead, a guideline will serve as a decision-making aid to help a practitioner decide the best possible course of care for a particular patient, combining clinical judgment, the best available research, and the patient’s individual characteristics and preferences. Longterm, clinical treatment guidelines can help improve patient care by identifying gaps in research and treatment where more work is needed to develop effective interventions.

I was interested to see that only one of the members of the APA treatment guidelines committee is a private practitioner; another member is with the VA. All others are academician/researchers. While this composition favors quality science, it runs the risk of overlooking real-world needs.

There are researchers who focus their attention on dissemination as well as implementation of the science that already exists. The APA has recently run multiple articles on this new field.

Until we figure out effective strategies to get evidence-based practices integrated so they can help people, they’re not much better than a nice publication,” says the National Institute of Mental Health’s David Chambers, DPhil, who directs the institute’s dissemination and implementation research arm.

Getting research into the real world, by Tori Deangelis, is an excellent examination of the resources and the challenges. DeAngelis quotes Dr. Gregory Aarons:

“Our job isn’t just to create new knowledge, it’s to improve the health-care delivery system,” he says. “Sometimes that means proceeding with the best available information and learning from experience, even though we’d prefer to wait for something a lot more definitive.”

While dissemination and implementation science are multidisciplinary by nature, psychologists with strong research backgrounds and an interest in systems change have much to contribute, adds psychologist Gregory Aarons, PhD, an implementation researcher and associate professor at the University of California, San Diego.

And in Evidence-based psychology in action, DeAngelis reports on an implementation of evidence-based practice in a community program utilizing a structured framework for this implementation.

The challenges of incorporating evidence-based practices (EBPs) into clinical practice has resulted in a whole field called implementation science. The National Implementation Research Network has as its goal “to close the gap between science and service by improving the science and practice of implementation in relation to evidence-based programs and practices. I can imagine this discipline becoming a major field as we attempt to control the costs of health care.

Resources abound. The US Department of Health and Human Services Agency for Healthcare Research and Quality (AHRQ) maintains web resources aimed at dissemination of evidence-based practices, including those for mental health. The Substance Abuse & Mental Health Services Administration (SAMHSA) has long provided access to research and protocols for EBPs.

One of my biggest concerns about possible future mandates for the use of evidence-based practices is the challenge of getting treatments from paper to practice. Implementation science may help.

How is your organization proceding in adopting EBPs? Do you see a role for behavioral health specialists in implementation? What do you think about how we will get there? Please enter your comments below.

Has the U.S. Become an Anti-Scientific Nation?

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On Sunday night our book club met to discuss Richard Dawkins’ Greatest Show on Earth. While I had a bit of difficulty with his style of writing, the data Dawkins presents in explication and support of evolution is exhaustive. Even with such overwhelming evidence, he reports that a full 44% of Americans surveyed in 2008 do not believe that evolution occurred. They deny the fact that all life forms on earth, including humans, descended from some common ancestor; Dawkins calls them 44% ‘history-deniers.’

On Saturday night, we finally saw Avatar. Among the themes explored in this movie was the strong prejudice that exists today against science and scientists. Technology…the practical outcome of scientific endeavor… is valued. Everyone on that space settlement was a technician of some sort. But the science that got them there and the science allowing the use of real avatars was denigrated by the majority.

A few weeks ago, I wrote about behavioral health professionals use of evidence based treatments. Behavioral health professionals and psychologists in particular are generally well-trained scientists, having a good understanding of the scientific method plus training in critical judgement of research. One goal of this education is to choose the soundest methods of providing care. And yet, large numbers of psychologists indicate that they do what they “believe” is best for their clients rather than what scientific research indicates is likely to provide the most effective course of treatment.

Numerous writers and commentators have bemoaned the state of science education in this country. At one time the U.S. was generally regarded to be the place to get the best education in science. Students from across the world came to the U.S. to study. Some stayed, some returned to their home lands to teach others. A 2007 article in the Christian Science Monitor ranked U.S. high school students 29th in the world in science literacy. While others would argue this figure, the common perception is that we have slipped as a nation in our interest in, and understanding of, science.

Simultaneously, we have become technology addicts. I would venture to say that many young people who are technology drones have never really thought about the science that went into creating the devices they cannot live without. Nor do they care that they do not know about the science. Just make sure that they continue to have access to their toys and to the technological infrastructure that supports them.

I believe this trajectory puts us as a nation in a very vulnerable position. Technological innovations are only one aspect of scientific endeavors. The knowledge gained from pure science is one of the things that keeps me most in touch with my creativity and my humanity. Take a listen sometime to Science Friday, an NPR program and podcast that weekly explores a whole variety of science topics and themes. It is impossible for me to listen to more than two or three of these shows without coming away with a book I want to read. I referenced one of these shows in my article on Evidence Based Treatment.

Those who provide behavioral health care services are unlikely to find the bulk of their work taken over by technology. There will be technologies that facilitate treatment and technologies that become treatments, but the bulk of human services will still be provided by humans. Assuring that we are good scientists, or at least can judge when a study is good science, is a worthwhile goal for behavioral health providers of every stripe.

How do you rate our science literacy? Are you interested in or bored to tears by science? Do you see science as relevant to your life…as a human being or as a provider of services?

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Evidence Based Treatment and Psychology

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As a psychologist trained 30 years ago in a Boulder-model scientist practitioner training program in clinical psychology, the ability to critically evaluate research and to determine its application to the treatment of my patients was an essential part of my practice and of my outlook on clinical psychology. That initial training fed my early interest in Cognitive Behavioral Therapy. I still have vivid recollection of attendance at my first two-day workshop conducted by Jeff Young (Jeffrey E. Young, Ph.D.) on Beck-style Cognitive Therapy of Depression, a workshop that had profound impact on the treatment I provided. Even my later identification as a Feminist Therapist and my questioning of programmed, patriarchal methods that elevated the therapist above the patient was always tempered by the need to use the scientific method in my practice and in my life. (I’ll credit George Kelly’s ‘man, the scientist’ and Franz Epting, Ph.D. for that.)

As I have mentioned previously, I have been retired from active practice since 1993. Imagine my surprise to learn this past November that clinical psychologists value their own experience and the guidance of their colleagues more than they do the dictates of science. In fact, according to the authors of Current Status and Future Prospects of Clinical Psychology: Toward a Scientifically Principled Approach to Mental and Behavioral Health Care by Timothy B. Baker, Richard M. McFall, and Varda Shoham, some clinical psychology training programs are downright anti-scientific. They believe the solution to this ‘problem’ is a new system of accreditation for training programs. NPR’s Science Friday aired an episode on this topic on December 4, 2009. The show, entitled The Science of Clinical Psychology, is a quick way to get a sense of the much longer paper.

This paper and the PR blitz surrounding it including an article in The Washington Post by the authors, has received strong reaction from practicing psychologists, directors of training programs in clinical psychology and divisions of the American Psychological Association (APA).

While some would describe the Baker, McFall, Shoham article as politically motivated and an attempt to wrest accreditation away from the APA, it seems to me that focusing in a defensive fashion on political motivations accomplishes little. Perpetuation of the ad hominem arguments used in the paper will not get us very far. Perhaps we should focus instead on the notion of scientific support for mental health and behavioral treatments, how clinical research might be encouraged, how evidence-based treatments (EBTs) might be most effectively promulgated, and whether psychologists are alone in their hesitance to adopt EBTs.

In his December editorial in Current Psychiatry Online, Henry A. Nasrallah, M.D. suggests that psychiatrists also could benefit from self-evaluation regarding their use of EBTs. Below is an excerpt from Dr. Nasrallah’s article:

PSYCHIATRISTS’ TRACK RECORD

 The Schizophrenia Patient Outcomes Research Team5 assessed how the treatment of 719 patients with schizophrenia conformed to 12 evidence-based treatment recommendations. Overall, <50% of treatments conformed to the recommendations, with higher conformance rates seen for rural than urban patients and for Caucasian patients than minorities.

A study using data from the National Comorbidity Survey6 found that only 40% of respondents with serious psychiatric disorders had received treatment in the previous 12 months, and only 15% received care considered at least minimally adequate. Four predictors of not receiving minimally adequate treatment included being a young adult or African-American, living in the South, suffering from a psychotic disorder, and being treated by physicians other than psychiatrists.

Finally, a recent survey of psychiatrists’ adherence to evidence-based antipsychotic treatment in schizophrenia7 showed: 1) mid-career psychiatrists more adherent than early or late-career counterparts; 2) male psychiatrists more adherent than female; 3) those carrying a large workload of schizophrenia patients more likely to adhere to scientific literature.

It would appear that psychologists and psychiatrists all need a stronger push toward use of EBTs.

In the world of community behavioral health, Medicaid and Medicare are pushing providers of care to the chronically mentally ill toward use of EBTs. SAMHSA has an entire section of its web site dedicated to EBTs. SAMHSA’s National Registry of Evidence-based Programs and Practices (NREPP) contains a searchable database of interventions for the prevention and treatment of mental and substance use disorders. The database currently contains 150 entries along with a method for submitting programs for review and inclusion in the database. The NREPP has the potential for becoming a clearinghouse for effective behavioral health treatment interventions.

How does your organization approach the issue of evidence-based treatments? What is your take on the current controversy in the field of clinical psychology? How do you imagine we ought to move forward in advancing scientifically-tested approaches to mental health treatment? Given the costs of health care, this seems like an extremely important issue for all providers of behavioral health services to address.

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Meaningful Use & Behavioral Health Providers

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I have been avoiding writing about the second draft of the Meaningful Use of Electronic Medical Records (EMRs) definition released by the federal Health IT Policy Committee on July 16. I had been hoping I would hear something that would make me believe the definition would in some significant way benefit our customers. I am disappointed to report that it still appears that the ARRA stimulus funds for adoption of EMRs will be largely unavailable to behavioral health providers, except psychiatrists, unless some change is made through regulation.

Just to clarify my statements above: ARRA provided $19 billion in funding for EMRs. $2 billion will be provided to the states to distribute for grants. Community Behavioral Health Organizations (CBHOs) are included in the eligible organizations for these funds. Unfortunately, it appears that this funding is going to be used by the states where they see fit. I have heard from a representative of at least one children’s psychiatric hospital who was told that funding would be used by the state to build Health IT (HIT) infrastructure and data exchange capability. They were informed that providers could get their funds from the incentives. I will be very curious to see how much (if any) of that $2 billion winds up in the hands of providers of any sort.

The larger part of the funding, $17 billion for Medicare and Medicaid incentives, is designed to encourage providers to purchase EMRs and use them to improve the care of their patients. Of the providers eligible to receive these reimbursements, the only behavioral health providers who are eligible are psychiatrists and certain nurse practitioners. They would purchase a system and then receive reimbursements for some or all of what they have spent depending on a variety of complex formulas. If you are a psychiatrist and you do not see Medicaid or Medicare patients, you are not eligible for funding. If you do treat these populations, you will only be able to get funding from one source, Medicare or Medicaid. The amount of reimbursement you can receive depends upon what proportion of your patients are Medicaid or Medicare recipients, along with other complex criteria.

Senator Jay Rockefeller of West Virginia introduced the Health Information Technology Public Utility Act of 2009 in late April. This bill was intended to assure that certain “safety net” providers like rural clinics and mental health providers could also access funds. That bill has not moved. Unless something happens in regulation, it is not likely that psychologists, social workers, mental health counselors, addiction treatment programs, psychiatric hospitals, or community behavioral health service providers are going to benefit from the stimulus funds to help purchase EMRs.

That said, the Health IT Policy Committee did seem to take into account the input they received from the public about the initial attempt at defining “meaningful use of EMRs”. They have drafted a plan that widens definitions, expands time frames, and provides more opportunities for providers to demonstrate that they are using EMRs meaningfully. Their PowerPoint presentation does a good job of summarizing their points. Details can be found in their updated grid and matrix.

1. The primary goal of the definition is to improve the outcomes of healthcare interventions through data capture and sharing and use of advanced clinical processes. They want providers to focus on health outcomes, not on software. HIT is to be a primary aid to healthcare reform, not use of software for the sake of earning incentive money.

2. It is the intention of the committee that there be a phasing in of meaningful use criteria. The public was concerned that if providers could not meet the 2011 criteria in 2011, they would always be behind the train. The committee now recommends that a provider who does not adopt an EMR until 2012 (or 2015) will start at the 2011 criteria and progress from there.

3. Changing work flows to assure the proper use of IT tools is an essential part of the solution. Trying to use CPOE (computerized physician order entry) can actually cause problems if there are not work flow modifications to make sure the process flows smoothly. An unintended consequence of CPOE in at least one study was diminishing of appropriate care because it was inconvenient to enter the order for the care.

4. Since data-based decision support is the real payoff of using an EMR, the committee wants to see this happen sooner, even it if means implementing only one rule in the decision making process.

5. Since engaging patients in their care is crucial to reduction in costs, providing access to an electronic version of their health record needs to be higher priority and come earlier in the process than previously envisioned.

6. Certification of software should be done by more than one body; CCHIT should not be the sole arbiter of which products should be certified.

While the Health IT Policy Committee has now presented their second draft of the “meaningful use” policy, it has until the end of 2009 to finalize the rules. It appears, however, that the direction is set. If you want to get some of the incentive money to help you buy an EMR, you will need to demonstrate that you can use that EMR and can report a variety of metrics to show how your practice is handling a number of issues. So far, none of those metrics are vaguely related to mental health.

Do you expect your organization/practice to be seeking incentive funding to purchase an EMR? How are you proceeding to assure that outcome? Do you think it is important for behavioral health to be included in the adoption of EMRs?

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