Scope of Work
An inappropriate decision to admit or discharge a psychiatric patient from an emergency room is often the starting point for a series of undesirable results. The individual inappropriately admitted is deprived of liberty and involved in a disruptive, stigmatizing event. Since each admission to inpatient psychiatric care costs the mental health system about $10,000, these admissions are also a costly misuse of scarce health care dollars. The individual who is inappropriately discharged does not receive the care he or she needs, and, in extreme cases, may engage in dangerous or violent behavior in the community. Over 135,000 emergency psychiatric assessments are conducted in New York's hospitals each year, and research shows wide variability in the resulting admission and discharge decisions.
The project the Office of Mental Health (OMH) proposed to the Center for Technology in Government (CTG) was designed to address this issue through the development of a computer-assisted decision model to support psychiatric assessments in emergency rooms. The decision support model and software developed are not meant to replace the physician or the physician's own expert judgment. Instead, they support the practitioner in gathering and considering all information relevant to an admissions decision.
The first objective of the CTG project was the development of a formal decision model for use in psychiatric assessments in emergency rooms. An effective and workable model required not only careful study of relevant research, but also required a consensus among experts. The Center for Policy Research at the University at Albany applied its extensive facilitation experience to this project objective. A group of 15 experts was brought together three times (in May, July, and September 1994) to define and reach consensus on the decision model. A selected group of three experts met a fourth time, in April 1995, to evaluate the readiness of the prototype for a field test.
The decision model produced by this first phase of the project specified the most important information needed for a psychiatric assessment and a method for combining individual items of information to provide guidance for a disposition decision. This model specified relationships among various items of information to key summary indicators or modules.
- Danger to Self Environmental Factors
- Danger to Others
- Client/Family Preferences
- Mental Health Status
- Availability of Services
- Functional Impairment
- Medical Conditions
- Substance Abuse
- Potential to Benefit from Treatment
The second objective was to create software for the decision model. This prototype system is a Microsoft Windows-based program that runs on a notebook computer and generates descriptive profiles for a client in each of the modules embodied in the model. These profiles are generated from users' answers to a set of approximately seventy-five questions about the client. Not all questions need be answered about a client; the system is capable of handling situations in which only partial information is available. The prototype system has two components: the user interface and the evaluation module. The user interface allows the clinician to supply information about the client. The evaluation module presents summary output in three formats: a scaled scoring, a graphical representation of those scores, and a short narrative analysis.
The third objective was to field test the software. A field evaluation comprised a first assessment of the structure, value, and usability of the tool in a hospital setting in one psychiatric ER. Evaluation results cover three topics: strengths and weaknesses of the prototype, its potential for future use, and general reaction to the technical aspects of the application.