A Nurse Is Reviewing the Medical Record of a Client Who Has Schizophrenia
J Am Med Inform Assoc. 2004 Sep-Oct; eleven(5): 358–367.
A Network-Based System to Improve Intendance for Schizophrenia: The Medical Computer science Network Tool (MINT)
Received 2003 Oct 30; Accepted 2004 Apr 5.
Abstract
The Medical Computer science Network Tool (MINT) is a software arrangement that supports the management of care for chronic illness. It is designed to improve clinical information, facilitate teamwork, and allow management of health care quality. MINT includes a browser interface for entry and system of data and preparation of existent-time reports. Information technology includes personal estimator–based applications that interact with clinicians. MINT is being used in a project to better the treatment of schizophrenia. At each patient visit, a nurse briefly assesses symptoms, side effects, and other cardinal issues and enters this information into MINT. When the doc afterward opens the patient's electronic medical record, a window appears with the assessment information, a messaging interface, and access to treatment guidelines. Clinicians and managers receive reports regarding the quality of patients' treatment. To date, MINT has been used with more than 165 patients and 29 psychiatrists and has supported practices that are consistent with improvements in the quality of care.
Schizophrenia is a chronic encephalon disorder that occurs in about one% of the population and manifests as symptoms of psychosis and disorganized thinking. It accounts for 10% of all permanently disabled people and three,200 premature deaths annually in the United States.1 During the past 2 decades, there have been dramatic advances in the handling of schizophrenia. New medications can improve symptoms and quality of life while causing fewer unpleasant side effects. Structured psychosocial treatments allow severely ill people to live successfully in the community and markedly improve their performance. Unfortunately, the majority of people with schizophrenia are not receiving appropriate care.ii While state governments spend approximately $16 billion per twelvemonth on public mental health services for adults, outcomes nether typical care are much worse than in state-of-the-art care. Quality problems are prevalent nationally in provider organizations, including the Department of Veterans Affairs (VA).
To accost this problem, the VA Health Services Research and Development service and Quality Enhancement Research Initiative (QUERI) take funded a number of projects, including Enhancing Quality Utilization in Psychosis (EQUIP).three , iv The EQUIP projection is implementing and evaluating a collaborative care model designed to better the quality of care for schizophrenia. Collaborative care models reorganize practice and typically involve changing the division of labor and responsibility, adopting new care protocols, and becoming more than responsive to patients' needs.5 In a number of chronic medical illnesses and low, researchers accept demonstrated that collaborative care improves wellness intendance processes and patient outcomes by keeping sick patients in intendance and ensuring the provision of appropriate medication and psychosocial services.half dozen , seven In EQUIP, established collaborative care principles have been applied to the handling of schizophrenia and are being evaluated in a randomized, controlled trial.
A primal component of EQUIP is the Medical Informatics Network Tool (MINT), a software arrangement that was adult to support both the EQUIP care model and enquiry evaluation. MINT supports care model implementation past helping clinicians collect, manage, and utilize patient-specific and scientific information in existent time. Information technology facilitates communication among members of the clinical team and provides reports that are used to manage care. MINT supports the research evaluation by maintaining data on all enrolled patients, their contact data, and dates for follow-up interviews. The EQUIP project, supported past MINT, is ongoing at the mental health clinics of two large VA medical centers in Southern California: the Long Embankment Healthcare System and the Greater Los Angeles Healthcare System at Sepulveda. This newspaper describes the objectives, compages, and functions of MINT and the utilization and operation of the system. Future applications are discussed.
Background
Key Bug with Treat Schizophrenia
Appropriate treatment for schizophrenia has been defined in a number of national treatment guidelines.viii , 9 , 10 Researchers take compared usual treatment at public clinics with advisable intendance and constitute large differences.2 Severely ill patients driblet out of treatment at a loftier rate, often unnoticed past decorated clinicians.xi Symptoms, side effects, and other bug are often not accurately assessed and medications non appropriately changed.12 Family members and other caregivers are usually not in contact with clinicians or not provided support or education. Although optimal handling is squad based, clinicians at typical clinics are often very busy and have difficulty coordinating care. Overall, there is a pressing need to improve data about the patient and to use it to focus care.
At mental health clinics, the clinical information that is typically bachelor has been of express use in improving intendance. Most clinics practice not have patient registries that include clinical data. Handwritten medical records tin be illegible, incomplete, difficult to access from more i site, and poorly organized. This makes information technology difficult for clinicians and managers to assess and ensure the quality of care.13 Most clinicians lack preparation in structured assessment tools, and accurate clinical assessment is often not a routine function of intendance.fourteen Centralized clinic databases typically contain only basic patient data from infrequent assessments.
Although intendance management strategies can improve patient outcomes, they are non being widely used in mental health. Researchers take found that md feedback, illness registries, clinical guidelines, and patient and caregiver education can better care and outcomes in a number of chronic diseases.xv The treatment of schizophrenia, like other chronic diseases, requires the accurate collection and use of both patient-specific and scientific data. This integration is peculiarly important given the complexity of the treatment regimens for schizophrenia and the seriousness of the risks faced by this population, such as victimization, substance abuse, and untreated medical disorders.
Using Clinical Information to Improve Care
Wagner and colleaguessixteen emphasize the importance of providing greater access to clinical information for all members of the wellness care team when managing chronic conditions. There must be ongoing clinical assessment combined with access to needed treatments. In schizophrenia, accurate assessment of the severity of symptoms (e.g., hallucinations) and medication side effects, e.g., akathisia (motor restlessness), requires specific training. Although psychiatrists may lack the fourth dimension and incentive to conduct ongoing assessments, master's degree–level clinicians can accurately appraise symptoms and side effects using structured instruments.17 Ensuring access to needed treatments requires both that the treatments be available and that clinicians make use of them. The availability of treatments can be improved by providing policy makers and managers with information regarding unmet patient needs. Clinicians can be encouraged to make use of available treatments by providing them with existent-fourth dimension data regarding patients' unmet treatment needs and past providing feedback when care is not appropriate.
The use of informatics systems to comport out these functions has been shown to ameliorate care and reduce errors in a number of chronic medical disorders.18 , 19 , 20 , 21 There are several types of effective informatics systems.22 Computer-based clinical determination support systems (CDSS) lucifer individual patient information to a cognition base for the purposes of assessment and making recommendations for clinical determination making. A review of research on CDSS found that two-thirds of studies reported benefits in doctor functioning and half-dozen of 14 studies reported improvements in patient outcomes.19 These studies involved a wide variety of targets (medication dosing, diagnosis, preventive care), diseases (asthma, hypertension, cancer, diabetes, AIDS), and medical services (mammograms, nursing care, vaccinations). Electronic medical records (EMRs) are electronic stores of notes, laboratory test results, patient bug, medications, and demographic data. They accept been shown to meliorate preventive intendance and adherence to clinical guidelines and to reduce errors in ordering medications and tests in principal and specialty care.23 , 24 , 25 , 26 , 27 Clinical reminders accept been constitute to increase adherence to clinical guidelines, especially in preventive care.nineteen , 20 , 28 Illness registries gather, organize, and provide access to condition-specific information for a panel of patients. Registries manage only selected data in a structured format, which differentiates them from more than comprehensive systems such as EMRs. Disease registries are increasingly used for medical disorders such as diabetes, asthma, congestive middle failure, and depression.15 They are believed to be a critical component of interventions that amend intendance and patient outcomes in chronic illness.29 For example, a disease registry for diabetes could include laboratory exam results on glucose (HgbA1c) and lipid levels, claret pressure measurements, and dates of contempo eye examinations. Care for a population of patients can then be improved by identifying and contacting patients who are doing poorly or who have not received necessary services. As well, services tin be reorganized when pervasive clinical problems are identified.
Since the late 1990s, the VA has had a fully electronic medical record called the Computerized Patient Record System (CPRS) and has had success using reminder systems in some chronic diseases.30 In primary care clinics, VA researchers have experimented with decision support software for hypertension31 and depression (Edmund Chaney, personal communication). However, in mental health specialty care, there has been less progress. It has become apparent that current medical records practise not contain reliable information on disquisitional clinical domains such as psychotic symptoms, medication side effects, and operation.14 In the VA, there has been routine collection of data in but two domains: (i) tardive dyskinesia, a side result of antipsychotic medication, and (2) global assessment of performance (GAF), a measure out that attempts to simultaneously charge per unit interpersonal, vocational, and symptomatic performance. The usefulness of these data has been express since tardive dyskinesia rarely occurs with current medications and the GAF is only reliable when administered by highly trained staff.32 Every bit a consequence, quality assessment has usually been based only on utilization data, such as medication dose, that are indirectly related to patient outcomes.33 Indeed, the Mental Wellness QUERI has come up to the conclusion that the major barrier to integrating research findings into do is a lack of routine outcome data to inform quality measurement.34
Design Objectives
MINT was adult to support both implementation of collaborative care and the research written report of this implementation. Pattern objectives for support of collaborative care included facilitating entry of key clinical information elements and admission to this information by the handling team in real time. Clinical information was to be provided to psychiatrists during their visit with the patient, since this is when information technology has maximum effect. Psychiatrists were to have one-click access to targeted treatment guidelines and an interface to efficiently communicate with other members of the treatment squad. They were to receive feedback regarding the extent to which they are compliant with treatment guidelines, in comparison with other psychiatrists at the clinic. Clinicians were to monitor patients' appointments and identify patients with inadequate follow-upwardly. Finally, projection staff required information regarding the frequency of patient assessments and the extent to which clinicians utilise the feedback information. All data had to be kept secure from unauthorized admission, and the organization was required to meet stringent VA information security requirements.
Design objectives for MINT support of the research evaluation included management of patient and clinician enrollment and contact information, follow-upwardly contacts, and research assessments. EQUIP includes an contained research squad that performs quantitative and qualitative assessments on an ongoing basis throughout the project. All patients undergo a structured interview by research staff at baseline and at approximately half dozen and 15 months. Given the large number of patients and clinicians enrolled at multiple sites, an efficient information management interface was desired. It was also desirable to integrate the research information with intendance management information regarding patients, and then data would non accept to be entered multiple times. Still, research staff had to be kept blind regarding whether particular patients and psychiatrists were in the intervention group to avert biasing the assessments.
Organisation Description
MINT consists of ii major components: (ane) a secure server accessible via the Internet using a standard Web browser interface, and (2) compiled applications running on personal computers (PCs) that interact with the clinician and the VA EMR. The server is on the Intranet within the VA firewall, and access is restricted to authorized users. Data are maintained in a countersign-protected relational database. Spider web pages are programmed in hypertext and Agile Server Page software and provide for user, clinician, and patient enrollment; entry and editing of data; study generation; secure messaging among the team; and editing of guidelines. Each user is assigned an admission level (read-only, clinician, research team, quality manager, local ambassador, or organisation administrator) that determines the functions that they can use. Compiled Visual Basic applications run on the clinicians' PCs. A popular-up application runs in the background and is the main signal of clinician access to MINT. An enroller application is used by project staff to enroll new clinicians and patients into the project's database. Both the pop-up and enroller communicate with the project server using Windows Socket protocols. MINT is compatible with Windows NT®, 2000, and XP and uses the high-speed local area networks of the VA.
▶ shows a schematic diagram of the overall system architecture and data flows. Data enter the MINT database from brief assessments of patients, from patients' medical records, and from project staff. MINT analyzes the information, displays them using the pop-up, creates a variety of reports for Web viewing or press, and runs a secure messaging system. Clinicians can use the pop-upwards to access treatment guidelines, send and receive messages, and disagree with brief assessments.
Schematic diagram of MINT functions.
User Services
Patient and Clinician Enrollment
All psychiatrists at the Sepulveda and Long Beach mental health clinics were recruited for EQUIP. All enrolled, except ane, for a total of 48 psychiatrists. Patients were eligible for the report if they had a visit during a six-month flow earlier study initiation, a 2nd visit during the first 6 months of the study, and a diagnosis of schizophrenia or schizoaffective disorder. Beyond both clinics, 292 patients are currently enrolled. Half the psychiatrists at each site were randomized, along with their patients, to the collaborative care model. The balance remained with care as usual.
MINT is agile just for patients and clinicians who are enrolled in EQUIP. This is accomplished starting with an enroller application that records the unique personal identification numbers (PINs) that the EMR (CPRS) uses to place patients and clinicians. Later on each clinician gives informed consent to enroll in the study, a project staff member runs the enroller application on a PC. The clinician logs into the CPRS, causing the CPRS awarding to generate window messages that include his or her Pivot. This PIN is read past the enroller, and his or her proper name and PIN are entered into the MINT database. To enroll a patient, a projection staff member runs the enroller awarding, opens the CPRS, and chooses the medical record for that patient. When this happens, CPRS messages a unique patient PIN. The enroller checks that the patient is not already in the database; confirms the patient's identity with the user; and enters the patient's name, social security number, date of birth, height, and Pivot into the MINT database. Within the MINT database, each clinician and patient is assigned to collaborative intendance or care equally usual.
Entry of Brief Assessments
The Institute of Medicine35 has asserted that "patient-specific clinical data" is critical to improving intendance. To collect this data, MINT houses a brief assessment module that is administered past a trained clinician (typically a nurse) before each psychiatrist visit. These "psychiatric vital signs" assess the following domains using established clinical scales: (1) patients' symptoms, including hallucinations, suspiciousness, delusions, disorganization, bizarre behavior, depression, and suicidality, as measured by the Brief Psychiatric Rating Scale36; (2) medication side effects, including akathisia,37 tardive dyskinesia,38 parkinsonism,39 sedation, sexual dysfunction, and weight proceeds; (3) medication compliance, measured as the number of days of compliance during the past week; (4) medical problems, including chronic conditions and torso mass index (BMI) as a measure of overweight40; (v) substance abuse based on the Clinician Rating Scale41; (six) housing status; (7) family/caregiver contact frequency and issues; and (9) the presence of contempo stressors. The assessment of these items averages most ten minutes and is usually conducted when the patient is waiting to meet with his or her clinician. When patients are severely ill or miss appointments, telephone assessments are performed. Cess data are directly entered into a page on the MINT Web site (▶). When desirable, staff use a secure wireless interface to access the Web site from a notebook calculator.
Web site folio for entering a brief assessment.
Feedback to Psychiatrists
Information technology has been suggested that providing patient-level clinical data to health care professionals can aid in the identification of previously unknown health problems, improve chronic disease management, and raise advice between patients and clinicians.42 Although the show that clinician feedback improves the care procedure and outcomes is mixed for a diversity of diseases, the testify for mental health information is stronger.43 Studies that have not shown an upshot on care accept concluded that clinical data needs to be provided in the context of a comprehensive affliction management program.43 , 44
MINT provides clinical data to psychiatrists during the clinical see, the fourth dimension that it is nigh likely to be used. When an enrolled psychiatrist accesses an enrolled patient'due south CPRS record, the pop-up application detects that both PINs are in the MINT database. If the patient is assigned to collaborative care, a window is then displayed in forepart of the CPRS nautical chart. The pop-upward window contains the ratings from the current and previous brief assessments (▶). Astringent problems are highlighted using a warning color. Clinicians tin disagree with an item's rating by checking a box and entering their assessment. There is a "guideline" box next to each symptom and side effect detail. When checked, a cursory guideline synopsis is displayed with links to Spider web sites that contain the full version of guidelines. When the clinician is done reviewing the pop-up, he or she clicks "OK" to return to the patient'south CPRS nautical chart. The pop-up can exist redisplayed at whatsoever time during the encounter.
Pop-up screen seen by psychiatrists.
In addition to providing information via the pop-up window, MINT uses its Spider web site to generate reports about the quality of intendance for specific patients. Psychiatrists log into the Spider web organisation, and view an "action item study" that lists active clinical problems for all their enrolled patients (▶). Problems are presented in 3 domains: (1) treatment compliance and related problems, (2) symptoms, and (3) medication side effects. When a patient has a severe trouble, information technology is indicated with an X. Psychiatrists exercise not see patient-level data for other psychiatrists' practices. Even so, they do meet summary statistics for their caseload and for the caseloads of other psychiatrists at their clinic. These consist of numerical and graphic representations of the proportion of a psychiatrist's patients that have a problem in each domain. Psychiatrists can employ this feedback to compare their performance with that of other psychiatrists.
Web site report on issues with the quality of patient care.
Messaging Among the Clinical Team
Effective care for chronic disease, and especially schizophrenia, often requires a team of clinicians with differing skills.45 An important characteristic of successful team intendance is strong communication among team members.46 MINT supports this advice. Later entering the brief assessment information, the nurse tin enter a text message. This message appears in the pop-up when the psychiatrist adjacent sees that patient. The psychiatrist can respond to the bulletin or start a new bulletin topic. Messages take proven to exist especially useful when there is a chronic medical issue, significant stressor, distress with family or caregivers, or a topic requiring farther elaboration or a response from the psychiatrist. In addition to viewing letters in the popular-upwards, any enrolled team member can log into the MINT Web site and view a message report that lists all new messages that have not yet been read. In that location is as well the option to respond to any message.
Management of Quality
Quality oversight is facilitated by using a patient registry, by brief assessment information, and by identifying patients who are not receiving needed services. A registry of patients and clinicians is maintained using the Spider web interface. This registry maintains patient contact information, whether consent has been obtained for caregiver contact, any caregiver contact data, the patient'due south primary psychiatrist, and the date of the last contact with the patient. For each patient in the registry, cursory assessment information are available. These information focus on key clinical problems for which at that place are prove-based treatments that substantially improve outcomes. Guidelines, including the Schizophrenia PORT, were used to make up one's mind which clinical problems to include. For example, psychotic symptoms and medication side effects are major targets of show-based intendance. Similarly, items assess family interaction and discord so that additional family education and support can exist provided when necessary.
Brief assessment information are displayed past the pop-upwards. They are also used to generate reports for clinical managers regarding care quality. These reports are identical to the activity detail report provided to individual psychiatrists, except that they contain patient-level information for all the psychiatrists at the clinic. The reports tin can exist used to identify psychiatrists who could benefit from extra support or resources to manage particular clinical problems. Information technology also identifies pervasive patient issues at the clinic.
MINT is too used to place patients who are using too few or no necessary services. For example, the MINT Web site produces an "appointment written report" that lists scheduled appointments for all patients. This is used to monitor receipt of services, identify when necessary follow-upwardly has not been arranged, and place opportunities to locate hard-to-observe patients. Data for this appointment report are automatically fatigued on a nightly basis from VA medical record databases.
Project Direction
The MINT Web site is used to manage data security, treatment guidelines, and implementation of the EQUIP care model. Project administrators utilise the Web site to manage access privileges for private users and to modify and update the treatment guidelines that are retrieved from the pop-upward. Management staff use the site to monitor progress with intendance model implementation. A "brief cess written report" lists the number of assessments that have been entered past each clinician during a given date range. In improver, a "clinician feedback report" lists for each psychiatrist information on his or her pop-up viewing during a given appointment range (▶). Data presented include the number of popular-ups that the psychiatrist viewed, the names of patients whose data were viewed, and the engagement of the most recent cess for each patient. This feature allows staff to identify when psychiatrists take received patient information. The report too presents the number of seconds that the psychiatrist viewed each pop-up, the number of letters that he or she has sent, and the number of times he or she disagreed with the brief assessments. Management staff utilize this feature to monitor how much attention individual psychiatrists are paying to the information presented to them.
Web site report regarding psychiatrists' use of the popular-up.
Status Report
MINT began operation at Long Embankment in January 2003 and at Sepulveda in April 2003. At fourteen months, MINT is managing information for 165 intervention patients. It is being used past two nurse quality managers who conduct cursory assessments and manage the study sites. It is used by 29 psychiatrists who are receiving the EQUIP intervention. MINT is also managing research enrollment for an additional comparison group of 19 psychiatrists and 127 patients that is continuing with usual care.
As shown in the ▶, clinicians take entered one,223 brief assessments and 1,100 messages into the database. The popular-up has been displayed to psychiatrists 2,201 times. Psychiatrists often view the pop-upwards more than than once while treating a patient. The window appears when they first open up the medical record at the beginning of the visit. They sometimes cull to recall the pop-up once again during the visit. If they write a patient note at a later fourth dimension in the day, it volition appear again. Psychiatrists accept disagreed with 49 of the nurses' cursory assessments and have written 78 messages back to other clinicians. The median time that psychiatrists have spent viewing each pop-up has been 7 seconds. Twenty-five percent of viewings are less than 3 seconds and 75% are less than 17 seconds. As psychiatrists have get accustomed to the interface, the median viewing duration has decreased gradually from 11 seconds during the offset calendar month to 4 seconds during month 14. The number of messages sent by psychiatrists has increased gradually over this time.
Table 1.
Utilise of MINT Service during Months 1 through xiv of Care Model Implementation*
| Implementation Month/Twelvemonth | Site Full | Project Total | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Service | Site | 1/03 | 2/03 | 3/03 | 4/03 | 5/03 | six/03 | 7/03 | eight/03 | nine/03 | 10/03 | 11/03 | 12/03 | 1/04 | ii/04 | ||
| Entry of brief assessments | LB | 56 | 42 | 47 | 48 | 41 | 58 | 41 | 39 | 44 | 47 | 35 | 45 | 44 | 45 | 632 | one,223 |
| Sep | 28 | 53 | 67 | 54 | 53 | 59 | 64 | 48 | 58 | 51 | 56 | 591 | |||||
| Entry of messages past clinicians | LB | 45 | 32 | 38 | 25 | 34 | 35 | 41 | 42 | 54 | 52 | eighteen | 33 | 34 | 39 | 522 | 1,100 |
| Sep | 26 | 52 | 63 | 53 | 53 | 67 | 72 | 42 | 44 | 49 | 57 | 578 | |||||
| Feedback to psychiatrists (pop-up) | LB | 26 | 67 | 26 | 129 | 106 | 74 | 92 | 64 | 47 | 92 | 73 | 158 | 70 | 42 | 1,066 | two,201 |
| Sep | 15 | 73 | 134 | 105 | 143 | 130 | 147 | 61 | 62 | 105 | 160 | i,135 | |||||
| Disagreement past psychiatrists | LB | 0 | 6 | 0 | 0 | 1 | ii | 0 | six | 5 | 4 | 6 | three | 4 | 3 | twoscore | 49 |
| Sep | 0 | 3 | iii | 0 | 0 | 1 | 0 | 0 | 0 | two | 0 | nine | |||||
| Entry of messages by psychiatrists | LB | 1 | 2 | 1 | 9 | 2 | xiii | 12 | four | 4 | 6 | 6 | 2 | 6 | 2 | 70 | 78 |
| Sep | 0 | 0 | 1 | 2 | 0 | two | 3 | 0 | 0 | 0 | 0 | 8 | |||||
Clinician and psychiatrist utilise of the pop-up, messaging arrangement, and reports has remained steady throughout implementation. During implementation, users have made numerous suggestions regarding improving the interfaces. Feedback has ranged from adjustments in visual aspects of the pop-up (e.g., increment font sizes) to add-on of new features (eastward.yard., add a "to practise list" of urgent problems to exist addressed). Changes have been fabricated based on user feedback. An iterative procedure of quality enhancement appears to take promoted active participation and motivation of those using the system.
Nine months after implementation of MINT, a sample (53%) of intervention clinicians were interviewed past an independent researcher regarding human factors characteristics, use, usability, and usefulness of the information science arrangement. The interview included established informatics questionnaires47 plus qualitative items regarding MINT components and the impact of MINT on treatment.
With regard to the collaborative care model, the bulk of psychiatrists found the information science system intuitive and easy to use and believed that it provided relevant clinical information in a visually appealing format. Although some psychiatrists viewed the pop-upward only speedily due to time constraints, well-nigh all stated that they learned important new information virtually their patients, specially related to the patients' social circumstances. Most stated that the assessment information reminded them to talk over side effects and medical issues with their patients. Some psychiatrists specifically stated that there was a amend level of patient intendance due to the additional information. One psychiatrist pointed out that the assessments were especially helpful with patients whose clinical stability varies. Psychiatrists acknowledged that they rarely accessed the treatment guidelines, and a few stated that they should apply the guidelines more than. The messaging organisation was used mostly by nurse quality managers to communicate information to psychiatrists. Overall, psychiatrists stated that MINT provided them with specific information that they used to improve their handling conclusion making.
Nurse quality managers written report that MINT has made it possible to proactively monitor the intendance of a population of chronically ill patients. Assertive outreach has been made to patients who have missed appointments or who take had inadequate follow-up given the severity of their illness. There accept been anecdotal reports from clinicians and nurses that advice has been enhanced amid the clinicians regarding the intendance of individual patients, facilitating teamwork and provision of advisable services.
MINT has also been very helpful to staff who manage the clinical and enquiry components of the EQUIP project. With several clinicians and hundreds of patients enrolled in the project, staff accept reported that MINT has been invaluable in ensuring that participants have research follow-up interviews on fourth dimension and that problems with implementation of the intervention can be chop-chop identified and resolved.
With regard to improving care, MINT Web site reports indicated that in that location was a severe, pervasive problem with overweight at both clinics. At the Sepulveda and Long Beach clinics, 74% of people with schizophrenia were overweight (BMI >25) and 40% were obese (BMI >30). This is even worse than the general U.S. adult population, in which about 65% of people are overweight and 31% are obese.48 Acting on these MINT data, dispensary managers identified resources for counseling regarding nutrition and practice. Since this time, 73% of the patients who are overweight take received individual and/or group wellness counseling, often nether a standardized protocol. Additionally, psychiatrists take been alerted to address weight bug in their medication treatment. Guideline-concordant approaches to this include changing to a medication with less weight proceeds liability, or adding medications that tin can reduce weight proceeds.
MINT Spider web site reports take likewise indicated that many patients have astringent, persistent psychotic symptoms, despite trials of numerous medications. Clozapine is a medication that is substantially more effective for these patients, but its use requires regular blood monitoring. Specific organizational structures need to be in identify to check these claret tests and dispense medication refills, yet these are lacking at many clinics. The implementation of MINT raised awareness of these barriers. A centralized clozapine clinic was created at Sepulveda and referral procedures for clozapine at Long Embankment were improved. In full, 43 patients have been referred for clozapine and two have been switched to this medication.
Additionally, MINT Spider web site reports identified that many patients with ongoing clinical problems (astringent psychotic symptoms, noncompliance, or family stress) accept family unit contact at least one time per calendar week. The majority of these patients consented to the clinical team contacting their family. All patients who gave consent were offered a family intervention, resulting in 67 referrals. Twelve accept received family or caregiver counseling, 3 families refused whatsoever intervention once contacted, and two families were provided with education and information regarding customs resources.
Discussion
MINT is designed to ameliorate the quality of care at the patient, clinician, and practise levels. At the patient level, MINT identifies specific problems that demand to be addressed, such as psychosis or homelessness. At the clinician level, MINT identifies when psychiatrists should consider new strategies for dealing with problems in their panel of patients. At the exercise level, MINT identifies pervasive problems that crave changes in the organization of intendance.
Data from the research evaluation indicate that the MINT informatics system is well received and provides clinical information that has been used to amend treatment decisions. Results indicate that the information provided in the popular-up prompts clinicians to assess side effects and physical problems and non just symptoms. Although psychiatrists were still spending the same corporeality of time with patients (20-minute sessions), it is possible that this fourth dimension was used more finer given the boosted clinical information provided past MINT. Referrals for weight management, clozapine use, and family services have increased substantially and may lead to improved patient outcomes. Organizational changes have occurred that have improved access to intendance.
MINT has a variety of potential uses in psychiatric disorders and other chronic medical illnesses. Information technology should be useful in large, multisite efforts to improve the quality of care. Potential applications also include situations in which feedback to clinicians is desired during the treatment visit or key clinical data need to be managed over time. MINT is easy to incorporate into usual practise at busy clinics and is readily adjustable to local needs. The user interface is intuitive and like shooting fish in a barrel to utilise. In EQUIP, very brief training was sufficient for almost all users. Dissemination should be affordable, especially within the VA given that it has a standardized national EMR. Further modifications volition be required for clinics working with paper charts. Whatever the local medical tape situation, the vast majority of our wellness care organizations share a pressing need for improved clinical information. This is specially true in mental health, where substantial progress in improving intendance will require that improved information systems are integrated into day-to-24-hour interval clinical operations.
Notes
Supported by the Department of Veterans Affairs through the Health Services Enquiry & Development Service (RCD 00-033 and CPI 99-383) and the Desert Pacific Mental Illness Research, Education and Clinical Middle (MIRECC) and by the NIMH UCLA-RAND Heart for Research on Quality in Managed Care (MH 068639).
The authors thank Sun Hwang, Qing Chen, Kuo-Chung Shih, Daniel Mezzacapo, Michelle Briggs, Donna Edible bean, Christopher Reist, Kirk McNagny, Christopher Kessler, EQUIP clinicians, and the Long Beach and Greater Los Angeles VA Information Resources Management Services for their contributions to the project.
Whatsoever opinions expressed are only those of the authors and exercise not necessarily represent the views of any affiliated institutions.
References
1. Young Equally, Magnabosco JL. Services for adults with mental illness. In: Levin BL, Petrila J, Hennessy KD, (eds). Mental Wellness Services: A Public Health Perspective. second ed. New York, NY: Oxford University Press; 2004, pp 177–208.
2. Lehman AF. Quality of care in mental health: the case of schizophrenia. Wellness Aff (Millwood). 1999;18(5):52–65. [PubMed] [Google Scholar]
iii. McQueen L, Mittman BS, Demakis JG. Overview of the Veterans Health Assistants (VHA) Quality Enhancement Inquiry Initiative (QUERI). J Am Med Inform Assoc. 2004;eleven:339–43. [PMC free commodity] [PubMed] [Google Scholar]
iv. Young As, Mintz J, Cohen AN. Clinical calculating: using information systems to improve intendance for persons with schizophrenia. Psychiatr Serv. 2004;55:253–5. [PubMed] [Google Scholar]
five. Von Korff M, Gruman J, Schaefer J, Curry SJ, Wagner EH. Collaborative direction of chronic illness. Ann Intern Med. 1997;127:1097–102. [PubMed] [Google Scholar]
six. Wells KB, Sherbourne C, Schoenbaum Chiliad, et al. Touch of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. JAMA. 2000;283:212–20. [PubMed] [Google Scholar]
seven. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, part ii. JAMA. 2002;288:1909–14. [PubMed] [Google Scholar]
eight. Lehman AF, Kreyenbuhl J, Buchanan RW, et al. The Schizophrenia Patient Outcomes Inquiry Team (PORT): updated treatment recommendations 2003. Schizophr Bull. 2004 (in press). [PubMed]
nine. Veterans Health Administration. Clinical Guideline for Management of Persons with Psychoses, Version 1.0. Washington, DC: Department of Veterans Affairs; 1997.
10. American Psychiatric Association. Do guideline for the treatment of patients with schizophrenia, 2nd edition. Am J Psychiatry. 2004;161(2 suppl):1–56. [PubMed] [Google Scholar]
11. Immature As, Grusky O, Jordan D, Belin TR. Routine upshot monitoring in a public mental health system: the impact of patients who leave care. Psychiatr Serv. 2000;51:85–91. [PubMed] [Google Scholar]
12. Young Every bit, Sullivan G, Burnam MA, Beck RH. Measuring the quality of outpatient treatment for schizophrenia. Arch Gen Psychiatry. 1998;55:611–7. [PubMed] [Google Scholar]
13. Dick RS, Steen EB, Detmer DE, (eds). The Computer-Based Patient Record: An Essential Technology for Health Intendance, Revised Edition. Washington, DC: National Academies Press, 1997.
14. Cradock J, Young As, Sullivan Yard. The accuracy of medical record documentation in schizophrenia. J Behav Health Serv Res. 2001;28:456–65. [PubMed] [Google Scholar]
fifteen. Casalino Fifty, Gillies RR, Shortell SM, et al. External incentives, information technology, and organized processes to ameliorate health care quality for patients with chronic diseases. JAMA. 2003;289:434–41. [PubMed] [Google Scholar]
xvi. Wagner EH, Austin BT, Von Korff M. Organizing intendance for patients with chronic affliction. Milbank Q. 1996;74:511–44. [PubMed] [Google Scholar]
17. Ventura J, Greenish MF, Shaner A, Liberman RP. Training and quality assurance with the Brief Psychiatric Rating Scale: "the drift busters". Int J Methods Psychiatr Res. 1993;3:221–44. [Google Scholar]
eighteen. Balas EA, Austin SM, Mitchell JA, Ewigman BG, Bopp KD, Dark-brown GD. The clinical value of computerized information services. A review of 98 randomized clinical trials. Arch Fam Med. 1996;v:271–8. [PubMed] [Google Scholar]
19. Hunt DL, Haynes RB, Hanna SE, Smith K. Effects of computer-based clinical determination back up systems on dr. performance and patient outcomes: a systematic review. JAMA. 1998;280:1339–46. [PubMed] [Google Scholar]
20. Shea S, DuMouchel W, Bahamonde L. A meta-analysis of xvi randomized controlled trials to evaluate computer-based clinical reminder systems for preventive care in the ambulatory setting. J Am Med Inform Assoc. 1996;3:399–409. [PMC complimentary article] [PubMed] [Google Scholar]
21. Lobach DF, Hammond WE. Computerized decision support based on a clinical practise guideline improves compliance with care standards. Am J Med. 1997;102:89–98. [PubMed] [Google Scholar]
22. Hersh WR. Medical informatics: improving health care through information. JAMA. 2002;288:1955–8. [PubMed] [Google Scholar]
23. Rollman BL, Hanusa BH, Gilbert T, Lowe HJ, Kapoor WN, Schulberg HC. The electronic medical record. A randomized trial of its impact on primary care physicians' initial direction of major low. Arch Intern Med. 2001;161:189–97. [PubMed] [Google Scholar]
24. Garrett LE Jr, Hammond WE, Stead WW. The effects of computerized medical records on provider efficiency and quality of care. Methods Inf Med. 1986;25:151–seven. [PubMed] [Google Scholar]
25. Rissover J. Half dozen electronic medical record systems. Med Software Rev. 1997:1–8.
26. Safran C, Rind DM, Davis RB, et al. Guidelines for management of HIV infection with reckoner-based patient's record. Lancet. 1995;346(8971):341–6. [PubMed] [Google Scholar]
27. Young DW. Improving the consistency with which investigations are requested. Med Inform (Lond). 1981;6:xiii–seven. [PubMed] [Google Scholar]
28. Balas EA, Austin SM, Mitchell JA, Ewigman BG, Bopp KD, Chocolate-brown GD. The clinical value of computerized information services: A review of 98 randomized clinical trials. Curvation Fam Med. 1996;5:271–8. [PubMed] [Google Scholar]
29. Metzger J. Using Computerized Affliction Registries in Chronic Disease Care. Oakland, CA: California Healthcare Foundation,, 2004.
30. Cannon DS, Allen SN. A comparison of the effects of estimator and manual reminders on compliance with a mental wellness clinical do guideline. J Am Med Inform Assoc. 2000;7:196–203. [PMC gratuitous commodity] [PubMed] [Google Scholar]
31. Goldstein MK, Hoffman BB, Coleman RW, et al. Patient safety in guideline-based determination support for hypertension management: ATHENA DSS. J Am Med Inform Assoc. 2002;9(vi suppl):S11–vi. [Google Scholar]
32. Roy-Byrne P, Dagadakis C, Unutzer J, Ries R. Bear witness for limited validity of the revised global cess of functioning calibration. Psychiatr Serv. 1996;47:864–vi. [PubMed] [Google Scholar]
33. Young AS. Dosages and outcomes. Psychiatr Serv. 2003;54:1547. [PubMed] [Google Scholar]
35. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press, 2001. [PubMed]
36. Ventura J, Lukoff D, Nuechterlein KH, Liberman RP, Green MF, Shaner A. Brief Psychiatric Rating Scale (BPRS) expanded version (iv.0): scales, anchor points and administration manual. Int J Methods Psychiatr Res. 1993;three:227–43. [Google Scholar]
37. Barnes TR. A rating calibration for drug-induced akathisia. Br J Psychiatry. 1989;154:672–half dozen. [PubMed] [Google Scholar]
38. Marsden CD, Schachter M. Assessment of extrapyramidal disorders. Br J Clin Pharmacol. 1981;eleven:129–51. [PMC free article] [PubMed] [Google Scholar]
39. Simpson GM, Angus JW. A rating calibration for extrapyramidal side effects. Acta Psychiatr Scand Suppl. 1970;212:xi–9. [PubMed] [Google Scholar]
40. National Institues of Health (U.s.). Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. From National Institutes of Health (US). Available at: http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm. Accessed Mar 30, 2004.
41. Mueser KT, Drake RE, Clark RE, McHugo GJ, Mercer-McFadden C, Ackerson TH. Toolkit: evaluating substance abuse in persons with severe mental illness. From The Human Services Research Constitute. Available at: http://world wide web.mentalhealth.org/cmhs/CommunitySupport/research/toolkits/pn6ch2.asp. Accessed Mar 30, 2004.
42. Deyo RA, Carter WB. Strategies for improving and expanding the application of health status measures in clinical settings. A researcher-programmer viewpoint. Med Care. 1992;30:MS176–86, discussion, MS196–209. [PubMed] [Google Scholar]
43. Espallargues M, Valderas JM, Alonso J. Provision of feedback on perceived wellness status to wellness intendance professionals: a systematic review of its touch. Med Care. 2000;38:175. [PubMed] [Google Scholar]
44. Fihn SD, McDonell MB, Diehr P, et al. Effects of sustained audit/feedback on self-reported wellness condition of principal care patients. Am J Med. 2004; 116(iv):241–8. [PubMed] [Google Scholar]
45. Young As, Forquer SL, Tran A, Starzynski M, Shatkin J. Identifying clinical competencies that back up rehabilitation and empowerment in individuals with severe mental disease. J Behav Health Serv Res. 2000;27(3):321–33. [PubMed] [Google Scholar]
46. Liberman RP, Hilty DM, Drake RE, Tsang HW. Requirements for multidisciplinary teamwork in psychiatric rehabilitation. Psychiatr Serv. 2001;52:1331–42. [PubMed] [Google Scholar]
47. Lewis JR. IBM reckoner usability satisfaction questionnaires: psychometric evaluation and instructions for use. Int J Hum Comput Interact. 1995;7:57–78. [Google Scholar]
48. National Eye for Health Statistics. Wellness, The states, 2002. Hyattsville, Dr.: U.s. Department of Health and Human Services, Centers for Disease Control and Prevention; 2002.
Articles from Journal of the American Medical Computer science Association : JAMIA are provided here courtesy of Oxford University Press
fitzpatrickduat1980.blogspot.com
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC516242/
0 Response to "A Nurse Is Reviewing the Medical Record of a Client Who Has Schizophrenia"
Post a Comment