Information Systems
and
Improving Care for
Schizophrenia
Alexander S. Young, MD, MSHS
Amy N. Cohen, PhD
Jim Mintz, PhD
VA Desert Pacific MIRECC
UCLA
Schizophrenia
 Chronic
disorders of thought
 Prevalence of 0.5% - 1%
– 16% of the VA’s health care budget
– 10% of all disabled people in U.S.
 Effective
–
–
–
–
treatments are underused
assertive community treatment (ACT)
appropriate medication management
caregiver involvement and support
vocational rehabilitation (IPS)
Improving Care for Chronic Illness
Community
Health System
Resources and Policies ------ Organization of Health Care
SelfManagement
Support
Informed,
Activated
Patients &
Caregivers
Delivery
System
Design
Decision
Support
Collaborative
Care
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Functional and Clinical Outcomes
From: E.H. Wagner & RWJF Improving Chronic Illness Care Initiative
Informatics has a Central Role
 Clinical
information
– routine, structured collection of clinical and
outcomes data
– management of a panel of patients over time
 Decision
support
 Improve communication among
clinicians
 Support self-management & caregivers
– education, access to medical records,
appointments, refills, etc.
Improving Care for Schizophrenia
 How
to apply chronic illness strategies
to schizophrenia?
 Major challenge: lack of routine, valid
outcomes data
– no important lab tests or vital signs
– medical records lack key clinical data
 Potential
solutions
– assessment by physicians or other clinicians
– assessment by trained raters
– self-assessment by patients
Routine Outcomes Data:
Self-Assessment by Patients
 Patient
Self-Assessment System (PAS)
– audio computer-assisted self-interviewing
– touch-screen computer
– web browser
PAS: Psychometric Study
 Methods
–
–
–
–
patients with schizophrenia or bipolar (n=90)
BASIS-R, side-effects, QOL
face-to-face vs. computer assessment
20 minutes apart separated by distracter task
 Results
– very good correlations (r = .81 - .99)
– similar means (p < .05)
– computer: easier, preferable, faster
EQUIP: Evaluating an Intervention to
Improve Care for Schizophrenia
 Chronic
care model
 Controlled trial in schizophrenia
– assertive management of care
– activation of caregivers
– routine assessment (“psychiatric vital signs”)
by nurses trained to research standards
– feedback of data on quality
 MINT
– “Medical Information Network Tool”
MINT: Implementation
 Functioning
for 18 months
– supporting research and clinical care
 Used
–
–
–
–
by clinicians
1700 assessments, 3000 pop-ups, etc.
well received & useful
has improved assessment and information
improved team communication
 Used
by managers
– led to weight and clozapine programs
EQUIP: Evaluation
 Controlled
trial
– VA HSR&D grant
– 2 clinics, 25 psychiatrists, 400 patients
– randomize by psychiatrist
 Process
evaluation
– organizational change, barriers, facilitators
 Evaluate
effect of the model on
– treatment appropriateness
– symptoms, side-effects, QOL, satisfaction
EQUIP: Results So Far
 Chronic
care model implemented
– feasible and useful
 Organizational
change
– clozapine
– services for over-weight
 Treatment
appropriateness
– assertive care
– families & caregivers
– medications
Conclusions
 Current
quality
– appropriate treatments are often not
received
 National
–
–
–
–
strategy for implementation
activate & involve patients
monitor patient need
ensure access to evidence-based services
implement chronic illness principles
References

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

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Cradock J, Young AS, Sullivan G: The accuracy of medical record
documentation in schizophrenia. Journal of Behavioral Health Services &
Research. 2001; 28: 456-65
Chinman M, Young AS, Schell T, Hassell J, Mintz J: Computer-assisted
self-assessment in persons with severe mental illness. Journal of Clinical
Psychiatry. 2004; 65: 1343-1351.
Young AS, Sullivan G, Burnam MA, Brook RH: Measuring the quality of
outpatient treatment for schizophrenia. Archives of General Psychiatry.
1998; 55: 611-7
Young AS, Magnabosco JL: Services for adults with mental illness. In:
Levin BL, Petrila J, Hennessy KD, eds. Mental Health Services: A Public
Health Perspective. New York: Oxford University Press; 2004:177-208.
Young AS, Mintz J, Cohen AN: Clinical computing: using information
systems to improve care for persons with schizophrenia. Psychiatric
Services 2004; 55:253-5
Young AS, Mintz J, Cohen AN, Chinman MJ: A network-based system to
improve care for schizophrenia: the medical informatics network tool
(MINT). J Am Med Inform Assoc. 2004; 11: 358-67.
 Acknowledgements
– VA HSR&D and QUERI (RCD 00-033, CPI 99-383,
MHS 03-218)
– VA Desert Pacific Mental Illness Research, Education
and Clinical Program (MIRECC)
– NIMH UCLA-RAND Center for Research on Quality in
Managed Care
 For
further information
– Alex Young
– ayoung@ucla.edu
– MIRECC, West Los Angeles VA Healthcare Center,
11301 Wilshire Blvd. (210A), Los Angeles CA 90073