BOX 6-1
Improving Care Using Information Technology

Mark is a 38-year-old veteran with schizophrenia who receives health care at a Veterans Administration (VA) medical center. He lived with his parents until they died 2 years ago and has since lived with his brother Sam and Sam’s family. He has not worked recently, but he volunteers at a local library and lives off his military pension. Recently he enrolled in EQUIP, a project aimed at improving care for people with schizophrenia by applying illness management principles effective in treating other chronic illnesses. EQUIP uses the VA’s electronic health record (EHR) enhanced by an information system that supports management of care, structured psychiatric evaluations, and secure messaging between clinicians. As a result, Mark’s treatment team was alerted to several emerging problems that might have been missed with the old paper chart system.

The old paper charts included handwritten notes that were sometimes illegible and typically did not include useful psychiatric assessment data. The charts often arrived after a scheduled appointment, or not at all, and whether Mark had scheduled or kept medical appointments was unknown to his treatment team. With the enhanced EHR, Mark’s psychiatrist was able to review Mark’s full, up-to-date record, including the team nurse’s routine assessments of Mark’s symptoms and other problems. These assessments indicated chronic medical problems, including diabetes, a heart problem, a possible seizure disorder, obesity, and smoking. Several problems needing immediate attention were highlighted.

With the EHR and information system, the team received a list of previously scheduled and upcoming appointments. It was clear that Mark had missed multiple visits and was at risk for severe medical complications. The information system also indicated serious problems at home. With the previous paper charts, contact information and Mark’s preferences regarding family contact were not documented. Now, this information was easily at hand, and his brother was called. He told the team that Mark was having daytime sleepiness that led to his missed appointments and that Mark was awake late at night, disturbing the family, and overeating. Most disturbing was that he was irritable and combative when confronted by Sam about these problems. Sam wanted to help Mark and had promised their parents to care for him. But he did not know what to do.

Previously, communication among the team took place only when someone remembered to bring a patient up at the weekly team meeting. Now, team members received a regular report on the clinical status of each of the patients under their care. They used a secure electronic messaging system to discuss Mark’s problems. The team implemented a comprehensive behavioral program addressing sleep scheduling, caloric intake, exercise, and missed visits. Clinicians used the messaging system to update each other and ensure that their advice and instructions to Mark were consistent at each visit. The computer screen displayed updated messages when each clinician looked at Mark’s medical record. A clinician also reviewed a weekly EQUIP-automated appointment report and used it to remind the family about upcoming appointments.

Mark began making it to his appointments regularly. Sam was included in medication change decisions. He ensured that the new medications were taken correctly and reported any changes to the team. With time, Mark began to express an interest in living more independently and working for pay. By the end of the project,

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