Evidence-Based Practices in Medications:

Psychiatric Services and Clinical Knowledge Enhancement System

(PSYCKES)4/7/20054/7/2005

Edith Kealey, MSW, MAEdith Kealey, MSW, MAMolly Finnerty, MD, DirectorMolly Finnerty, MD, Director

Bureau of Adult Services and Evaluation ResearchBureau of Adult Services and Evaluation Research

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Outline

OverviewOverview Motivation, Timeline, & Data Flow/ChallengesMotivation, Timeline, & Data Flow/Challenges

PSYCKES DemoPSYCKES Demo Types and examples of contentTypes and examples of content

Preliminary ResultsPreliminary Results From OMH databases, evaluation, and usage logsFrom OMH databases, evaluation, and usage logs

Future PlansFuture Plans DevelopmentDevelopment Analysis OpportunitiesAnalysis Opportunities

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Motivation Purpose / RationalePurpose / Rationale

Missing or inaccurate historical data can lead to duplicative Missing or inaccurate historical data can lead to duplicative care, deviation from guidelines, and longer patient stayscare, deviation from guidelines, and longer patient stays

Raw data not enough – need intelligent decision supportRaw data not enough – need intelligent decision support Administrative data is available and can be harnessed for Administrative data is available and can be harnessed for

clinical decision supportclinical decision support Goals / Intended OutcomesGoals / Intended Outcomes

Give MDs and supervisors access to dataGive MDs and supervisors access to data Support guideline-driven, cost-conscious QI at the state, Support guideline-driven, cost-conscious QI at the state,

facility, ward, and patient levelsfacility, ward, and patient levels Track change over time of fiscal and clinical quality Track change over time of fiscal and clinical quality

indicators at state and local levelsindicators at state and local levels

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Development Timeline

YearYear PSYCKES ActivitiesPSYCKES Activities19981998 Development of printed patient-level report summarizing Development of printed patient-level report summarizing

all pharmacy data since 1989 (6 hospitals)all pharmacy data since 1989 (6 hospitals)

19991999 Field testing; physicians request a) timeline graph and b) Field testing; physicians request a) timeline graph and b) caseload summarycaseload summary

2001-20022001-2002 Printed report for all adult, non-forensic hospitalsPrinted report for all adult, non-forensic hospitals

2002-20032002-2003 Move to Web-based format, adding timeline graph, Move to Web-based format, adding timeline graph, caseload summaries, and management reports with drill-caseload summaries, and management reports with drill-down capabilities. Beta testing in one hospital with 5 MDsdown capabilities. Beta testing in one hospital with 5 MDs

2003-20042003-2004 Addition of Infobuttons. Run expanded to include all Addition of Infobuttons. Run expanded to include all hospitals. Commissioner commits to statewide hospitals. Commissioner commits to statewide implementation.implementation.

Dec. 2003-Dec. 2003-April 2005April 2005

Version 1 implementation in all adult facilities.Version 1 implementation in all adult facilities.

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PSYCKES Data Flow

1. NKI IRDB

OMH Atomic Pharmacy Data Warehouse

3. State MCD Database

4. Additional OMH & State Databases: MHARS, etc.

2. OMH MEDSoln & DMHIS

PSYCKES web-based application

1. State Inpatient EBP Initiatives

2. Community Initiatives (MCD population)

3. State Outpatient Initiatives

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Data Quality Challenges WhoWho

Patient – multiple conflicting IDsPatient – multiple conflicting IDs Attending – irregular updates; resident/limited permit MDs not Attending – irregular updates; resident/limited permit MDs not

enteredentered WhatWhat

Drugs – misspelled drugs; new / systemic onesDrugs – misspelled drugs; new / systemic ones Diagnosis – only admitting, not updatedDiagnosis – only admitting, not updated

WhenWhen Dates – gaps / overlapsDates – gaps / overlaps Frequency – multiple, hard-to-interpret valuesFrequency – multiple, hard-to-interpret values

WhereWhere Ward – conflicting codes; poor linkage to PatientWard – conflicting codes; poor linkage to Patient

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PSYCKES Content & Demo

Performance MeasuresPerformance Measures EBP/CPG based quality indicatorsEBP/CPG based quality indicators Fiscal measuresFiscal measures Data quality measuresData quality measures

Medication reportsMedication reports Attending level reportsAttending level reports Patient level reportsPatient level reports

DemoDemo

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EBP-based Performance Measures

Measures developed and incorporated into PSYCKES Measures developed and incorporated into PSYCKES for state inpatients at facility and clinician level:for state inpatients at facility and clinician level: Antipsychotic polypharmacyAntipsychotic polypharmacy Psychotropic polypharmacyPsychotropic polypharmacy Combinations of antipsychoticsCombinations of antipsychotics Dosing within recommended rangeDosing within recommended range Duration within recommended rangeDuration within recommended range Clozapine eligibilityClozapine eligibility Dosing frequency > QDDosing frequency > QD

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Fiscal Measures

Measures developed and incorporated into Measures developed and incorporated into PSYCKESPSYCKES Cost savings by doseCost savings by dose Cost savings by antipsychotic monotherapyCost savings by antipsychotic monotherapy Cost savings by form/frequency (to date Cost savings by form/frequency (to date

developed for risperidone only)developed for risperidone only)

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Data Quality Measures

Measures developed for state inpatients Measures developed for state inpatients incorporated into PSYCKES incorporated into PSYCKES Missing date of discharge (false inpatient Missing date of discharge (false inpatient

status)status) Use of unknown frequenciesUse of unknown frequencies Inappropriate frequency / doseInappropriate frequency / dose Dosing gapsDosing gaps Concurrent admissionsConcurrent admissions

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Attending Caseload Summary

Patient SummariesPatient Summaries Good dose / duration?Good dose / duration? Antipsychotic HxAntipsychotic Hx

Guideline MeasuresGuideline Measures % doses high/low% doses high/low % durations high% durations high % polypharmacy% polypharmacy % long stays not on % long stays not on

clozapineclozapine Calculated on trial Calculated on trial

basisbasis

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Patient Prescribing Summary

DemographicsDemographics Medication HistoryMedication History

ClassificationClassification AdmissionAdmission Medication TrialMedication Trial

DetailsDetails Start / StopStart / Stop Max Dose (Trial)Max Dose (Trial) Dose TimelineDose Timeline Discharge DoseDischarge Dose

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Medication History Timelines

Used to determine which Used to determine which regimens were effective in regimens were effective in the pastthe past

Dark-gray background Dark-gray background shows outpatient statusshows outpatient status

Medication history Medication history grouped by drug classgrouped by drug class

12- or single-year views12- or single-year views Log scale – actual dose Log scale – actual dose Normalized scale – Normalized scale –

whether dose in rangewhether dose in range

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Fictitious PC

Demo for MDs – Click Clinical Reports to …

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Fictitious PC

Fictitious PC

… Select self from list of MDs to …

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Fictitious PC

Fictitious PC

… View own caseload. See that sole patient on 3 antipsychotics for 2 years, but Clozapine never tried. Click patient name for more details …

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Fictitious PC

Fictitious PC

Fictitious PC

Fictitious PC

Fictitious PC

Fictitious PC

Fictitious PC

…See all drug trials, with their durations, doses, and effectiveness. Click Timeline to see that …

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Maximum of Risperidone 8 mg qd

Fictitious PC Fictitious PC

Discharged on Risperidone 16 mg qd

…Higher dose Risperidone worked at another hospital in 1995, so switch to Risperidone or Clozapine

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Demo for Clinical Supervisors – Click Antipsychotic Regimens by Patient to see …

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Fictitious PC

Fictitious PC

… Patients on most complex drug regimens. Click on Patient name to review prescribing history.

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Click Concurrent Antipsychotics by Attending to see …

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… Distribution of polypharmacy by MD. Click on a physician to review caseload and patient-level data.

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Demo for Operations – Fiscal reports show potential cost savings from improved guideline compliance, such as …

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…Maximizing reasonable mono-therapy

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…Reducing very high doses

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Easy Access to Knowledge Resources:Infobuttons and Web Sites

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Current PSYCKES Limitations

Contains only psychotropic medicationsContains only psychotropic medications Two months out of dateTwo months out of date Tracks only current inpatientsTracks only current inpatients Many data quality and completeness issues have been Many data quality and completeness issues have been

challenging to resolve challenging to resolve

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Implementation Status (as of March 31, 2005)

• 650+ registered users statewide650+ registered users statewide• Trainings held at 17 adult facilitiesTrainings held at 17 adult facilities

• Interactive, hands-on formatInteractive, hands-on format• # sessions based on number of staff to be trained# sessions based on number of staff to be trained• Follow-up technical support by phone and e-mailFollow-up technical support by phone and e-mail

• Trainings at remaining adult facilities to be completed Trainings at remaining adult facilities to be completed by April 2005by April 2005

• Implementation planning initiated at 4 interested Implementation planning initiated at 4 interested children’s facilitieschildren’s facilities

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PSYCKES Usefulness Data

Rated the single most useful source of information about Rated the single most useful source of information about patients’ medication histories (8.8 on a 10-point scale)patients’ medication histories (8.8 on a 10-point scale)

High average usefulness scores (6 or more on a 7-point scale) on High average usefulness scores (6 or more on a 7-point scale) on all dimensions of a standardized scale, including “useful in job” all dimensions of a standardized scale, including “useful in job” (6.6), “accomplish tasks more quickly” (6.4), and “improve job (6.6), “accomplish tasks more quickly” (6.4), and “improve job performance” (6.4)performance” (6.4)

Physicians without access to PSYCKES correctly identified only Physicians without access to PSYCKES correctly identified only 24.6% of their patients’ medication trials, but improved to 24.6% of their patients’ medication trials, but improved to 76.9% with PSYCKES76.9% with PSYCKES

Physicians using PSYCKES recorded a 59.8% decrease in the Physicians using PSYCKES recorded a 59.8% decrease in the time needed to assemble a medication historytime needed to assemble a medication history

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PSYCKES Usability Data

High average usability scores (6 or more on a 7-point High average usability scores (6 or more on a 7-point scale) on all dimensions of a standardized scale, scale) on all dimensions of a standardized scale, including “easy to become skillful” (6.2),”easy to use” including “easy to become skillful” (6.2),”easy to use” (6.1), and “clear and understandable interaction” (6.0)(6.1), and “clear and understandable interaction” (6.0)

Discomfort with computers is not a barrier to Discomfort with computers is not a barrier to navigating PSYCKESnavigating PSYCKES Average post-training test scores for those who rated Average post-training test scores for those who rated

themselves below average on a “Computer Comfort themselves below average on a “Computer Comfort Scale” similar to the average of all respondents (89% Scale” similar to the average of all respondents (89% vs. 88%)vs. 88%)

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QI Performance over Time (as of 12/31/04, adult facilities only)

Quality IndicatorQuality Indicator 1/31/041/31/04 12/31/0412/31/04

>= 2 antipsychotics*>= 2 antipsychotics* 47.9%47.9% 44.6%44.6%

>= 5 psychotropics>= 5 psychotropics 16%16% 16%16%

>1000mg/day CPZ eq>1000mg/day CPZ eq 44%44% 42%42%

>1year trial length>1year trial length 41%41% 43%43%

> QD dosing> QD dosing 39%39% 38%38%

*statistically significant decrease (p<.05)

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PSYCKES Use by User Role (Facility Users)

Type of userType of user Registered Registered usersusers

Active users* (% Active users* (% of reg. users)of reg. users)

Avg. hours Avg. hours used/mo used/mo (SD)(SD)

Avg. hits/ mo Avg. hits/ mo (SD)(SD)

AdministrationAdministration 8080 53 (66%)53 (66%) 2.0 (3.0)2.0 (3.0) 15.2 (19.7)15.2 (19.7)

Attending Attending PsychiatristPsychiatrist

138138 101 (73%)101 (73%) 2.5 (3.7)2.5 (3.7) 15.4 (16.2)15.4 (16.2)

Supervising Supervising PsychiatristPsychiatrist

3939 31 (80%)31 (80%) 2.8 (4.4)2.8 (4.4) 16.3 (20.4)16.3 (20.4)

Other ClinicalOther Clinical 212212 47 (22%)47 (22%) 2.3 (5.3)2.3 (5.3) 13.1 (25.2)13.1 (25.2)

TOTALTOTAL 469469 232 (50%)232 (50%) 2.4 (4.0)2.4 (4.0) 15 (19.6)15 (19.6)

*“Active user” means someone who used PSYCKES outside of a training session. Data is as of 1/13/05.

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PSYCKES Use by Attending Psychiatrists

Variation across facilitiesVariation across facilities % of active users ranges from 31% to % of active users ranges from 31% to

100%100% Avg. hours used per month ranges from Avg. hours used per month ranges from

0.3 to 4.20.3 to 4.2 Avg. hits per month ranges from 3.1 to Avg. hits per month ranges from 3.1 to

22.922.9 Variation within facilitiesVariation within facilities

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Reasons for PSYCKES Use by Attending Psychiatrists Medication History ReviewMedication History Review

To assess dose and duration of past trialsTo assess dose and duration of past trials To check what medications have not been tried To check what medications have not been tried To narrow scope of chart review (e.g., date trial To narrow scope of chart review (e.g., date trial

ended used to find reasons for discontinuation)ended used to find reasons for discontinuation) To check patients’ histories when transferred to new To check patients’ histories when transferred to new

wardward To confirm patient statements re: medication history To confirm patient statements re: medication history To supplement thinned/culled chartTo supplement thinned/culled chart

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Reasons for PSYCKES Use by Attending Psychiatrists (cont’d) SupervisionSupervision

To prepare for case reviewTo prepare for case review To brief supervisor during case presentationTo brief supervisor during case presentation

DocumentationDocumentation To prepare court documentsTo prepare court documents To prepare application for clozapineTo prepare application for clozapine To prepare discharge noteTo prepare discharge note

InformationInformation To obtain information about medications, guidelinesTo obtain information about medications, guidelines

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Reasons for PSYCKES Use by Supervisors

To review patient hx prior to/during To review patient hx prior to/during case conferencecase conference

To identify candidates for case reviewTo identify candidates for case review To identify candidates for clozapine (in To identify candidates for clozapine (in

conjunction with facility records)conjunction with facility records) Aggregate data used as basis for group Aggregate data used as basis for group

discussion of practice stylediscussion of practice style

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Reasons for PSYCKES Use by Administrators

Tool for dialogue around QITool for dialogue around QI Tool for identifying data quality issuesTool for identifying data quality issues JCAHO JCAHO Strategic PlanStrategic Plan

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Future Activities:New Data (Versions 3 / 4) Medicaid Data Medicaid Data

Outpatient Pharmacy & Services to fill-in gapsOutpatient Pharmacy & Services to fill-in gaps Detect continuity of care; complianceDetect continuity of care; compliance

Lab ValuesLab Values Blood levels for drugsBlood levels for drugs

Clinical OutcomesClinical Outcomes Adverse Events (NIMRS) – falls, seclusionAdverse Events (NIMRS) – falls, seclusion Symptom Scores – BPRS/TMAP, QOL?Symptom Scores – BPRS/TMAP, QOL? Vital Signs / Side Effects – obesity, BP, …Vital Signs / Side Effects – obesity, BP, …

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Future Activities:New Report Development Fiscal ReportsFiscal Reports

Identify cost drivers, with drill-through to clinician, Identify cost drivers, with drill-through to clinician, patient, and drug levelspatient, and drug levels

Clinical ReportsClinical Reports Custom views for Adult and Child MH DiagnosesCustom views for Adult and Child MH Diagnoses Reports for co-occurring systemic disordersReports for co-occurring systemic disorders

Progress / Trending ReportsProgress / Trending Reports Fiscal and Clinical trends over timeFiscal and Clinical trends over time Statistical Analyses of changeStatistical Analyses of change

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Future Activities:Analyses Implementation Evaluation StudyImplementation Evaluation Study

Impact of use on clinical, fiscal, and patient Impact of use on clinical, fiscal, and patient outcomesoutcomes

Exploratory AnalysesExploratory Analyses Complex relationships between medications, Complex relationships between medications,

treatments, and outcomestreatments, and outcomes Hypothesized and emerging trends (e.g. using Hypothesized and emerging trends (e.g. using

Clementine data mining tool)Clementine data mining tool) Develop new business rules (e.g. knowledge bases Develop new business rules (e.g. knowledge bases

and KNAVE)and KNAVE)