March 5, 2014

The Ideal Tool for Health Care: Clinician Perspective

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Larry Culpepper, MD, MPH

Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts


In my previous blog post, I described the patient’s perspective on the ideal tool to guide mental health care in the patient-centered medical home (PCMH). Here, I consider the treatment team’s view, as well as existing building blocks for such a tool.

From the primary care team’s perspective, the tool should maximize transfer of information and communication with the patient and among the team. It should integrate into the PCMH’s medical record and efficiently summarize, including graphically, a patient’s functional status, symptoms, and disease concerns and priorities, highlighting both changes over time and comparisons with an appropriate reference population. The tool’s dashboard should provide summative information for a patient’s chronic disease and for PCMH population management and quality activities. It should push out alerts and reports both at the patient and panel level.

The tool would provide efficiency by using information to connect the patient to the right PCMH team professional. The tool will efficiently lead clinicians to diagnosis by highlighting problems in patient functioning and relationships, history, and symptoms requiring confirmation or further exploration. It can then help guide the patient and the professional in developing a shared understanding of the patient’s needs, strengths, and priorities and preferences upon which to develop a treatment plan.

During treatment selection, the tool might display expert guidance useful in individualizing therapy. Given the patient’s experiences, comorbidities (eg, pain, sleep dysfunction), or vulnerabilities (eg, early-life abuse), what treatments might be of particular value or high risk? What potential drug interactions should be considered? For example, a patient with prior reactions to regular doses of medications metabolized by CYP450 2D6 might be identified as a possible “slow metabolizer,” suggesting low initial doses of some antidepressants.

In follow-up care, both short- and long-term, changes identified in functioning and symptom experience can support treatment adjustments. The tool also can provide clinicians with patients’ communications regarding other changes, such as new or different priorities and goals.

A further critical role for such a tool is communication and coordination at the time of transitions, such as hospitalization, referral to specialty care (eg, for intensive treatment of PTSD), and return to the primary care team, or geographic moves requiring a change in treatment team. Such transitions often not only are major sources of stress for the patient, decreasing coping and making them vulnerable to worsening health status, but are times of high risk for the occurrence of medical errors, both of commission and omission.

We have the building blocks for such an instrument. Measurement tools are available, and the required computing power is a reality, as are mobile platforms. Most patients are “wired.” The PHQ-2/PHQ-9, Bipolar CIDI 3.0, and the PC-PTSD/PCL screener-and-questionnaire combos already provide models of two-step strategies. Other tools available include quality of life instruments (eg, Q-LES-Q), functioning measures (eg, Cognitive and Physical Functioning Questionnaire, Family and Work APGAR scales, Sheehan Disability Scale), and less-used history tools. Cognitive assessment tools are available online, as are tools for conditions such as ADHD and substance abuse and for focused populations such as menopausal women, the elderly and adolescents, and disabled individuals.

The building blocks are beginning to be aggregated into primitive systems like the tool I describe. Virtual patient advocates are already being used for patient education processes (eg, In a pilot study, patients reported preferring the virtual advocate to clinical staff. The M3 tool, available with an app interface, measures multiple psychiatric conditions, provides individual disorder scores and a summary score, and tracks treatment and treatment response and side effects over time. In some VA regions, mental health technicians at central hubs can pull from a range of mental health instruments and remotely interview patients and collect data for clinicians. A number of online resources measure patient cognitive ability and provide clinical data to physicians (eg, )

The value equation has been missing in the past to drive the development and then refinement (likely to take years) of such a tool. However, steps in this direction are underway by multiple groups, who are approaching the task with a variety of motivations, including financially based (on either the potential for profit or the fear of loss) and grant-supported intellectual challenge and drive to improve care. As these efforts converge over the coming years, they will transform how we provide care, to the benefit of patients, professionals, and society.

Financial disclosure:Dr Culpepper is a consultant for Forest, Lundbeck, Merck, Sunovion, and Takeda; has received travel support from Pamlab; and is a stock shareholder of M3 (My Mood Monitor).

Category: Medical Conditions , Mental Illness
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