PSYCKES Overview

PSYCKES

The Psychiatric Clinical Knowledge Enhancement System

http://psyckes.omh.state.ny.us/

Summary PSYCKES is an award-winning clinical decision support, disease management, and business intelligence system used throughout New York State's mental health facilities to achieve cost-conscious, guideline compliant clinical quality improvement.
Background Improving psychiatric prescribing practices is an urgent public health issue. Practices often deviate from guidelines. Excessive use of psychotropics is a leading cost driver in state pharmacy budgets, and is correlated with increased obesity, diabetes, and significantly shorter life spans for mental health patients. Although New York has 15 years of prescribing data in administrative databases plus guidelines which could recommend improved medication regimens, those data were rarely available to decision makers. When they were, the data could not be effectively organized into the higher level concepts which clinicians and executives needed to rapidly picture the problems and identify solutions.
Vision An information system which will give all decision makers point-of-care, tailored access to patient's complete treatment history, rolled up as needed and organized to optimize the decision making process. The system will be easy to use, will make opportunities for clinical, quality and safety improvement obvious, will facilitate tracking and analysis of quality initiatives over time, and will have a side benefit of reducing overall costs.
Goals
  • For executives - provide dashboard and drill-down reporting which support cost-conscious clinical quality improvement, with ability to identify outliers statewide; profile agencies, practices and physicians; set and track performance targets; ensure initiatives are equitably applied across ethnic, gender, and age groups; and analyze the quality and cost benefits of such initiatives.
  • For physicians - (a) provide patient-level medication histories in tabular and graphical form which clearly indicate which drugs have been (in)effective or inadequately used in the past, easily informing decisions of which medication regimens should be tried next; (b) provide single-page roll-ups of all patients on caseload summarizing medication history and facilitating triage of clinical interventions.
  • For recipients - facilitate consumer empowerment, shared decision making and continuity of care by (a) providing complete medication history in format which eases review of historical (in)effective treatments, and (b) letting consumers share data and reports with other caretakers.
Timeline 2001-3: Consensus building, prototyping & field testing
2003-5: Statewide implementation in all 16 state hospitals for adults
2005-6: Integration into executive, statewide quality improvement initiatives
2007-8: Funded to be rolled out statewide (> 3000 programs), using Medicaid data
Awards 2004 Governor's Workforce Development Award
2005 Council of State Governments Innovation Award
Successes
  • Rated single most useful source of information, with usability & satisfaction scores of 6/7.
  • More than 250% increase in knowledge of past medication trials and speed of conducting complete medication history review.
  • 50% reduction in monitored indicators (e.g. antipsychotic polypharmacy) in 3 months
  • 50% reduction in unmonitored indicators in a year (e.g. other forms of polypharmacy, presence of any outliers)
  • Management of quality indicators showed no disparity by ethnicity, gender or age
Funding
  • Developed entirely in-house with state funds
  • ~$150K from industry + in-house funding for evaluation
  • $1.3 million in FY07-08 NY budget to develop/deploy PSYCKES statewide, with expected 1st year savings of $5.6 million, and second year savings of > $25 million.
  • Fundable scores received for AHRQ Demonstration Grant, but unfunded
Data Sources
  • 3 Centralized Pharmacy systems (Pharmakon, Med-Solution, McKesson MedsManager)
  • 2 Centralized Lab systems (LTMS, Cerner) - for lab results
  • 2 Electronic Medical Records (DMHIS, MHARS) - for admissions, diagnoses & services
  • Statewide Incident Management System (NIMRS) - for adverse events
  • Statewide Medicaid claims data (eMedNY) - for outpatient pharmacy and services
Challenges and Innovative Solutions
  • Uniquely Identifying Patients across Databases
    • Created custom master person index which supports missing and conflicting data
  • Data Quality, and Completeness
    • Developed novel cleaning strategies for gaps and overlaps across raw drug orders
    • Established iterative QI process for each variable with ability to review and fix data quality problems, plus track rates of missing or poor data over time
  • Modeling Effectiveness of Drug Trials - A Higher-Level Concept Needed for Decisions
    • Aligned cleansed drug orders with admission/discharge data plus guideline-based recommendations for dosing and treatment duration in order to determine which drugs had been tried for long enough at appropriate doses, and were also effectively associated with hospital discharge.
  • Efficiency & Generalizability
    • Architected and optimized novel data warehouse to support all data sources and facilitate all levels of roll-ups and drill downs needed for reports, timeline graphs and analytics.
  • Visualizing & Navigating Complex Relationships
    • Created novel business intelligence suite with hyperlinked reports providing high-level overview, with ability to zoom, filter & retrieve details on demand.
    • Created innovative timeline graphs showing complete clinical history, with ability to easily organize drug, lab and services data plus drill down into details.
    • Created generic management system of reports and graphs supporting tracking and comparing indicators over time, with filtering and/or profiling by factors including agency, doctor, location, diagnosis, ethnicity, gender and age.
  • Analytics
    • Created data marts to identify correlates of use and relationships between use and clinical outcomes
    • Created ability to visualize and monitor the effect of interventions on selected cohorts of patients, facilitating impact analysis of interventions.
  • Implementation & Training
    • The mental health field tends to be a late adopter of technology and data driven management, so the system had to be very user friendly and empowering.
Collaborations
  • Columbia University, Department of Biomedical Informatics - usability analysis
  • Columbia University, Division of Services Research - correlates of use; impact analyses
  • University of Rochester - business continuity planning; alignment with RHIOs
  • Rutgers University - prototyping privacy preserving integration of healthcare data
Alignment with Regional and National Health IT Initiatives Numerous states have developed Regional Health Information Organizations (RHIOs). Most aggregate recent prescription data (e.g. using RxHub to uniquely identify individuals) and lab data. Many support web-based prescription refills with drug-interaction checking. Few to none offer the more historical data or clinical decision support needed to optimally manage chronic diseases. PSYCKES innovations address many of these issues. NY State is beginning to partner with the RHIOs across the state to provide data and implementation knowledge to those RHIOs, seeking to make PSYCKES an information module available within amenable RHIO architectures. NY also plans to approach the industries involved in the National Health Information Network (NHIN) initiatives to make PSYCKES available within those systems. NY has also explored partnerships with the Veterans Health Administration (VHA). Lastly, NY is participating in the ONC-funded health IT initiatives, encouraging incorporation of the lessons learned and/or technologies from PSYCKES into those planning efforts. These include the CCHIT (Certification Commission for Healthcare Information Technology - advocating availability of PSYCKES-style tools within EHRs), and HISPC (Health Information Security and Privacy Consortium - ensuring that behavioral health-specific privacy and security issues are addressed, recommending some of PSYCKES techniques to enable privacy-preserving data sharing).
Dr. White's Role
  • Dr. White envisioned, architected, and oversaw the development of the PSYCKES system, identifying and addressing all of the aforementioned challenges. He spearheaded the economic and clinical impact analyses of the system and its refinement to become an executive management tool. He coordinated 50% of the grant-seeking activity, including the budget proposal which resulted in the FY07-08 $1.3 million budget. Together with the evaluation team, he ensured that the system could be widely adopted and easily used.
  • Dr. White also established and oversees all of the joint ventures and strategic alliances with regional and national health IT initiatives, and will be leading the business development efforts to solicit funds from industry.
Publications and Presentations
  • Finnerty M, Altmansberger R, Bopp J, Carpinello S, Docherty JP, Fisher W, Jensen P, Krishnan P, Mittleman M, Olfson M, Tricarico J, White TM, Felton C. Using State Administrative and Pharmacy Databases to Develop a Clinical Decision Support Tool for Schizophrenia Guidelines, Schizophrenia Bulletin, 2002; 28(1): 85-94.
  • Cohen T, Kaufman D, White TM, Segal G, Bennett-Staub A, Patel V, Finnerty M. Cognitive Evaluation of an Innovative Psychiatric Clinical Knowledge Enhancement System. MedInfo 2004, 2004: 1295-1299.
  • White TM, Finnerty M, Felton C. Implementation of a Novel, Psychiatric Clinical Knowledge Enhancement System to Improve Quality of Care and Reduce Pharmacy Expenditures. MedInfo 2004, 2004: 1906.
  • Uttaro T, Finnerty M, White TM, Gaylor R, Shindelman L, Reducing Concurrent Antipsychotic Regimens-PSYCKES. Adm Policy Ment Health & Ment Health Ser Res, 34 (1): 57-61.
  • Carpinello S, White TM, Finnerty M, Opler L. Using State Administrative Data as a Resource for Clinicians - Psychiatric Clinical Knowledge Enhancement System (PSYCKES). 58th Institute for on Psychiatric Services.
  • White TM, Opler LA. Achieving Rapid, Statewide Reduction in Polypharmacy via the Rational Psychotherapeutic Quality Improvement (RPQI) Initiative. Psychiatric Services. In preparation
  • White TM. PSYCKES: Infrastructure, Tools, and Strategies for High Quality, Cost Efficient Psychiatric Care. Journal of Services Research. In preparation