# Enhancing Lithium's use in the VA through the design, initial use, and assessment of the Lithium Support System (the ELeVAte Study)

> **NIH VA I21** · EDITH NOURSE  ROGERS MEMORIAL VETERANS HOSPITAL · 2020 · —

## Abstract

BACKGROUND: Lithium (Li) is a “gold standard” treatment for bipolar disorder and possibly for preventing
suicide. However, Li also has unique hazards due to its narrow therapeutic index. The suicide prevention
potential, toxicity risk, and monitoring of Li has become an intense focus of two VA offices, OMHSP and PBM.
This study builds on strong partnerships with OMHSP and PBM to develop an innovative near-real time system
to inform Li prescribers of events that sharply raise the risk of Li toxicity and of needed monitoring.
METHODS: This 1-year pilot study will develop a “Lithium Support System” (or “LiSS”) using near real-time
CDW data to track and notify prescribers of both upcoming and past due monitoring and of the occurrence of
clinical events that are powerful risk factors for Li toxicity. These clinical events are the initiation of interacting
medications by other providers, certain medical illnesses (kidney problems, infections, dehydration,
hyponatremia), and dose increases. Perhaps surprisingly, the VA’s computerized patient record system
(CPRS) does not provide notifications currently to Li prescribers in any of these circumstances. Our strong
partnership with OMHSP is evidenced by the fact that they have committed to provide us with code they have
already used to track overdue Li monitoring. The system will provide daily reports from CDW which will be
reviewed by a central evaluator (to prevent spurious notifications), with notifications then sent to prescribers via
encrypted email (and sometimes voicemail). (Email, rather than CPRS, is used in this pilot to reduce “alarm
fatigue”, facilitate tracking when notifications are read and prescribers’ immediate impressions to them, and to
permit guidance about appropriate clinical responses). The system will be test implemented at 2 sites (Bedford
and Boston VAMCs). We will evaluate process data (e.g., number of each notification type generated, central
evaluator time required, provider response times) and chart data regarding timing and types of clinical
responses (e.g., educate patient about toxicity symptoms, hold Li, decrease dose, switch medications). Survey
and interview data will be used to assess the usability and acceptability of the system. Nationwide data
analyses will seek to identify other predictors of Li toxicity to add to a “Phase 2” enhancement of the system
introduced in the study’s final months. Nationwide data will help estimate the toxicity episodes that might be
averted with broad implementation of the initial or expanded system, and examine clustering of toxicity events.
SIGNIFICANCE: Importance: Li toxicity is one of the major health concerns and perceived barriers to the use
of this highly valuable medication. Timeliness: Development of this system is urgent, given VA’s intense
interest in reducing Li toxicity episodes and the fact Li use may increase as a result of OMHSP’s efforts or a
large-scale Li suicide prevention trial approaching completion. Presumed Cost-ef...

## Key facts

- **NIH application ID:** 9610240
- **Project number:** 1I21HX002535-01A1
- **Recipient organization:** EDITH NOURSE  ROGERS MEMORIAL VETERANS HOSPITAL
- **Principal Investigator:** ERIC G. SMITH
- **Activity code:** I21 (R01, R21, SBIR, etc.)
- **Funding institute:** VA
- **Fiscal year:** 2020
- **Award amount:** —
- **Award type:** 1
- **Project period:** 2019-01-01 → 2019-12-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/9610240

## Citation

> US National Institutes of Health, RePORTER application 9610240, Enhancing Lithium's use in the VA through the design, initial use, and assessment of the Lithium Support System (the ELeVAte Study) (1I21HX002535-01A1). Retrieved via AI Analytics 2026-05-23 from https://api.ai-analytics.org/grant/nih/9610240. Licensed CC0.

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