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Using Technology to Advance Collaborative Care Research

Posted By Ben Miller, Tuesday, January 26, 2010
Updated: Thursday, June 2, 2011

There exists an opportunity to begin to leverage technology in such a way that we can advance collaborative care in ways only imaginable before. Just as the Collaborative Care Research Network (CCRN) has started increasing the effectiveness research for collaborative care practices, new and emerging technology allows for an advancement of research with large data sets consisting of millions of patients and hundreds of practices. This is a "game changer" that our field must take advantage of to begin to make a stronger research case for collaborative care.

A tale of two cities

Technology has changed everything. Never before have we had instant access to so much at one time. Need a new sweater at 3am? Done. Need a new car? Done. We are efficient and we are decisive. Technology means never having to say no to instant access to information. Everything is accessible and on our timeframe.

Wait, did I say everything? I meant everything but healthcare.

Healthcare remains the single largest non-immediately accessible service through technology. Interestingly enough, the last ten years have seen a push to integrate technology and healthcare in new and novel ways. Case in point, to be a patient-centered medical home (according to NCQA), one has to meet certain technology requirements, which include such things as the Availability of Interactive Website, Electronic Patient Identification, and Electronic Care Management Support. Bottom line, technology is important and everyone knows it, including healthcare stakeholders. Primary care has integrated electronic medical (or health) records (EMR) in a way that has changed the way medicine is practiced (hang on to this for a minute). Plus, many like the electronic medical records adoption as it saves money in the long run.

Now, consider the following. Primary care practices range in size and scope. However, electronic medical records are becoming pretty common in many medical settings. And, there is no shortage of different electronic medical records. Herein we find a small problem. If, different practices use different electronic medical records, how can we look across practices for themes, etc.? As many practice-based research networks do, common questions are asked to different practices and data is aggregated to answer the research question. This information was collected through chart reviews, card studies, etc. Does this change when we begin discussing electronic medical records? Possibly not if all practices used the same electronic medical record; however, practices are as uniquely enrolled in electronic medical records as they are in patient demographic. So, even if we wanted to examine across site research questions using technology and EMRs could we?

Enter DARTNet. The Distributed Ambulatory Research and Therapeutics Network or DARTNet is a federated network of different practice with different EMRs. DARTNet combines data from different EMRs to create a large database (think over 4 million patient lives) capable of answering almost any question one could ask with data from an EMR. Did I mention this was a game changer? Now, please click over to this cow and chicken picture as you visualize and think COLLABORATIVE CARE.

Yes, the connection I am attempting to make has to do with mental health/primary care and EMRs. You see, anytime we talk about collaborative care, there is the obligatory mention of the incompatibility of mental health imbedded in primary care and using medical records. Not so real life quote, but close: "The HIPAA police will arrest me". There does appear to be some issues here, which can be written about on another post so I will leave it at this: to truly examine collaborative care, our field is going to need to find a way to evaluate many of our core field specific assumptions in tandem with technology.

It may be more helpful for this post if I use a metaphor:

When you are in an art gallery and see a unique piece of art, the last thing you likely want someone to do is to come up to you and say: "this is what the artist meant when he created this piece..." You don't necessarily need interpretation of a specific piece as part of the beauty of art is your interpretation of the piece. DARTNet, technology, collaborative care, research it is all the same thing. I can tell you what could come from such relationships but would that really be what is best for you and "the piece?" I would encourage each of you to read the following article:

Pace, W. D., Cifuentes, M., Valuck, R. J., Staton, E. W., Brandt, E. C., & West, D. R. (2009). An Electronic Practice-Based Network for Observational Comparative Effectiveness Research. Annals of Internal Medicine, 151(5), 338-340.

For collaborative care to grow, technology is something we must grasp. To this end, without taking advantage of technology and research simultaneously are we relegated to the sidelines? I refuse to sit by and watch while everyone else has fun and makes a difference along the way - you?

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Comments on this post...

Gonzalo Bacigalupe says...
Posted Friday, July 8, 2011
Very strong piece to sort of close this series of very thoughtful entries. Not sure this is what I can draw from your ideas but I think that CFHA members have a double responsibility in immersing themselves in these emerging social technologies. Exploring them even if they are not sure why they would want to use them. Why? Because they may offer an opportunity for a more fluid integration. I am one of those who still does not understand the reluctance of mental health professionals to use the EMR as a clinical tool and at the same time still puzzled by the lack of attention that health care personnel pays to mental health complaints. May be having shared records, the ability to sift through this complex data may help. It is not enough to say, patient is depressed, it doesn't say much, we need context, relational data, and the details that thicken the story. These technologies facilitate the exchange. This is what the two minutes face to face conversation until now may have not been enough. I cannot convey all that info synchronously but may be we can asynchronously.
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Peter Y. Fifield says...
Posted Friday, July 8, 2011
Ben, I appreciate all of recent literary references ( so much I feel like I need to use one as well. When I think about the current cacophony of our health care system and how we will continue on the road to debunking the myth of mental/physical health I think of not only Something Wicked This Way Comes (Both Bradbury and MacBeth) and Antigone but also Frog and Toad and Friends and The Giving Tree. Is it just me or should the later of these be requisite reading for Congress?

Although I have my own reservations about technology and social medias ( and how they are changing the way we communicate inter-personally, I have no delusions about how they both are not only inevitable; but more so paramount to the success of integration—thus leading to better overall patient care. The difficulty that we face in doing so is having technology actually make things easier for patients and providers--not just create the illusion of simplicity. It appears that the CCRN can play a role in that facilitation process.

Although there is certainly enough fodder in the cannon for an entire separate piece on the HIPAA Police: briefly--- confidentiality and collaboration do not need be mutually exclusive. We have managed to trichotomized humans according to their physical, mental and addiction related behaviors. One day (and we are headed there but slowly) we will be promoting wholeness in health not its isolated parts. The necessary changes needed to put us back together exist on a continuum ranging from a global policy level to a local philosophical one but I can see how the CCRN can help promote this change and move us towards a concept of wholeness. Nice work with this network; we are eager to take part when a project comes up.
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Ben Miller says...
Posted Friday, July 8, 2011
Thanks, Gonzalo and Pete! I have to say that the more we can continue the dialogue with our healthcare brethren, the more likely we are to break down some of these traditionally dichotomized areas. Technology is a connector of sorts. It allows us to have easier access to data points, but gives us the flexibility to connect the dots on our own.

As we have discussed in other threads, technology should not trump the interpersonal, but rather expand and enhance.

Pete thanks for bringing up the trichotomy issue. Within mental health circles, there can often be jockeying for position according to whose tribe you align yourself with. In some ways it is like survivor where everyone is competing to win (or for scarce resources). Technology could be used to connect these disparate parts even within mental health.

Look for more from the CCRN soon!
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Randall Reitz says...
Posted Friday, July 8, 2011
BEN, As I'm preparing for my Sunday piece on "Collaboration in an EMR Environment" (A game changing blog post if you've ever seen one, Don't miss it!), I've been thinking about your work with CCRN. The question that comes to my mind is, what data points that predictably live within an EMR will you be able to easily and uniformly extract with your DARTnet data-culling "robots"?

As you describe integrating millions of patients into one database, I can't imagaine that you will have legions of psych majors doing the data input manually. Rather, you'll need to find data that are easily identifiable and able to be manipulated in the exact format that it is automatically extracted from the office's EMR.

What data points do you think are most germane to collaborative care? Do you anticipate being able to get a sense of inter-disciplinary collaboration? Of family-centered care? Of changes in health outcomes (i.e. PHQ scores)?

Do the robots have vacuum attachments and can I rent one for the weekend?
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Samantha Monson says...
Posted Friday, July 8, 2011
Echoing Randall's comment, I have questions, questions, and more questions! Which are the most important data points that will reliably predict the impact of collaboration across systems? Across payer sources? Across chronic diseases? The possibilities seem endless, and mining a meta-EMR would be nothing should of incredible. One piece of data I fear gets overlooked is provider experience of working in a collaborative environment. For example, I wish there were a way for the EMR to capture average visit lengths for MDs inside and outside of a collaborative environment as one means of cost savings. My thought is that having a handle on the patient's psych needs in this case allows the MD and patient to more efficiently focus on the patient's medical diagnoses. I believe such information could be available in a meta-EMR, as patient visit length is entered for billing purposes. But here I am arguing about how to show cost-savings, when really I'm worried that we're trodding down the same fee-for-service path our healthcare system has already traveled. Maybe we should be looking patient outcomes, instead? Or at least in conjunction with the cost? One thing is for sure, an efficient method of data collection and number crunching, like the one Ben references, would make the bottom line very happy!!!
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