Using Information Technology to Provide Measurement Based Care for Chronic Illness

Following the work of the Texas Medication Algorithm Project – a previous study funded by multiple funders, including the National Institute of Mental Health and the Robert Wood Johnson Foundation – the Sequenced Treatment Alternatives to Relieve Depression Trial developed the concept of measurement-based care (MBC) as a way to facilitate evidence-based care of depression. Elements of MBC include: 1) standard assessments of symptoms, function, and side effects; 2) use of critical decision points based on a state-of-the art algorithm for major depressive disorder (MDD); 3) consistent patient followup; and 4) performance feedback for clinical decisionmaking. The merging of MBC strategies with existing technology has been theorized to improve quality of care and outcomes of depression by maximizing delivery of appropriate treatment for MDD in ambulatory care settings, making it possible to electronically monitor whether there is consistent use of treatment practices that have been shown to be effective, as well as making MBC strategies accessible and user-friendly for medical providers. 

This electronic health record (EHR) clinical decision support system (CDSS) program was a collaboration between the University of Texas Southwestern Medical Center and the Centerstone Community Mental Health Center, Inc. The EHR-CDSS was instituted in 21 clinics and designed to facilitate MBC and improve medication management for patients with MDD to ensure that clinicians were using standardized measures to monitor three critical response domains: 1) symptom severity, 2) side-effect burden; and 3) treatment adherence. The specific aims of the project were to:

• Integrate a CDSS, facilitating MBC, with physician needs and the EHR at Centerstone.
• Evaluate EHR-CDSS's successful promotion of MBC in improving medication management.

In order to develop an EHR_CDSS that could effectively implement MBC, the project consisted of a three-stage process. Stage 1 was an end-user needs assessment that provided information about the needs of both the physician and the Centerstone care system. Stage 2 included a modification of the CDSS based on the information from the needs assessment. Finally, Stage 3 included the development of the CDSS to interface with Centerstone’s EHR.

The project team evaluated the extent to which implementation of the EHR-CDSS promoted the use of MBC as standard care for depression in both rural and urban settings. Two studies were conducted to evaluate the effects of using an EHR-CDSS to institute MBC. The first study looked at the impact across the entire health care system; the second was an in-depth evaluation of treatment practices and their effects in a sample of patients being treated for MDD.

Of 289 Centerstone employee surveys, 208 were analyzed as part of the needs assessment. This assessment revealed concern that the research would increase the time burden for Centerstone clinicians. Implementation results showed no statistical differences between baseline and week 24 with regard to any of the three outcome domains. However, the pattern of the results was encouraging and symptom decreases were seen early in the course of the study, following the pattern of similar studies.