Imagine if a patient came to see a doctor for high blood pressure. Now imagine if that doctor measured their blood pressure once on intake, and then never again, while continuing their treatment.
While the idea of not having quantifiable data to measure outcomes in medical care seems absurd, that is most often the case in behavioral health.
Systematically collecting and analyzing symptom ratings in behavioral health is known as measurement-based care (MBC). Providers implement standardized patient-reported outcome questionnaires like the PHQ9 or the GAD7 at regular intervals to track patient progress over time. The measures, which can capture side effects, functioning and patient experience, are then scored and analyzed to drive clinical decision-making.
“It’s crystal clear that without measuring how patients are doing, often we get it wrong,” Tom Zaubler, M.D., chief medical Officer at behavioral health company NeuroFlow, told Fierce Healthcare.
“Actually showing an individual their progress is in and of itself therapeutic,” echoed Monika Roots, M.D., co-founder and president of pediatric mental health provider Bend Health. Even if a patient is not progressing, seeing that can help identify behavioral patterns and encourage lasting change.
MBC offers tangible evidence of progress and can strengthen the therapeutic relationship. It is supported by the American Psychiatric Association and the American Psychological Association. Yet it is estimated that fewer than 20% of mental health practitioners use MBC.
“This is a public health initiative, it’s an economic initiative, to really help to manage the excess utilization that occurs when psychiatric illness is not treated — and it's an equity issue,” Zaubler said.
Lacking training, infrastructure
In a recent survey of 578 practitioners, EHR and practice management software company SimplePractice found that about half of clinicians practicing measurement-based care use pen and paper to collect data.
In 2009, the HITECH Act incentivized the meaningful use of electronic health records. But, it excluded mental health and substance use disorder providers. As a result, adoption of EHRs among these providers has lagged.
“It is very challenging for solo providers, in particular, to engage in measurement-based care because they typically do not have the infrastructure to make it successful,” Vaile Wright, Ph.D., senior director of the Office of Health Care Innovation at the American Psychological Association (APA), told Fierce Healthcare.
“It just adds more time,” echoed Jessica Schwartzman, Ph.D., clinical psychologist with the Division of Developmental-Behavioral Pediatrics and Director of the TREND Lab at Children’s Hospital Los Angeles. “There’s no billing structure for that time.”
There also is limited training on MBC for therapists as most practitioners are taught theory, not evidence-based interventions, per Roots.
“They’ve instead mostly been trained on treatment planning,” Roots said. Bend leverages its tech platform and EHR to systematically do questionnaires with patients. It uses 16 different measures, which takes a lot of training: “That’s not easy to do if you’re just scoring it by hand,” Roots said.
“There’s a lot of promise in measurement-based care,” Schwartzman told Fierce Healthcare. “We’re just not collecting that level of data.”
How tech can help
In November, SimplePractice launched a tool for MBC. It integrates into providers’ workflows, offering automatic measurements, interpretations of results and flags high-risk responses, as well as visual charts to show changes over time.
Meanwhile, Epic has tools to add data from questionnaires to patients’ charts and track multiple responses over time. This functionality has helped Vanderbilt University Medical Center collect its millionth pre-appointment survey, making it one of the largest collections of such surveys in the U.S., the health system claims.
Web apps cited by the APA like Better Outcomes Now and OQ-Analyst enable providers to administer questionnaires to patients on electronic devices, providing real-time reports and early warning treatment failure alerts.
Patient registries can also be used to identify which treatments work best for which patients. The APA’s Mental and Behavioral Health Registry is an electronic database that enables practitioners to enter encrypted data to track patients’ responses to treatment and report their outcomes to Medicare’s Merit-Based Incentive Payment System (MIPS). The American Psychiatric Association has its own MIPS registry, PsychPRO.
Meanwhile, platforms like NeuroFlow can screen and triage patients and refer them to the right level of care. It can also help providers understand how to interpret symptoms or talk about what a patient’s results mean and what treatment can help. This “makes humans smarter,” Zaubler said.
“It’d be challenging to do MBC without technology,” Schwartzman said. Beyond that, the industry needs to be “figuring out ways to not only build the tech, but then it’s the uptake, the implementation,” she added.
External incentives necessary
While tech solutions are an important component of scaling MBC, Wright acknowledged, they won’t be enough on their own. There also need to be incentives like increased reimbursement for clinicians doing the hard work of MBC, experts agree.
There is growing interest among payers as the industry shifts toward value-based payments, experts agree. The Centers for Medicare and Medicaid Services already implements a quality payment program for Medicare providers and uses benchmarks to compare provider performance, Wright offered.
But a major unresolved question remains: is MBC a separate, billable activity in addition to psychotherapy, or is it part of psychotherapy itself? “I think you can argue it either way,” Wright said. “I think that’s the challenge.”
Another issue is not only is there a limited supply of mental health providers already, but in-network providers are even more limited. “If they were to force a mental health provider to do this measurement-based care, I think there’s a lot of fear that those individuals would just stop accepting insurance,” Roots said.
“As more and more larger organizations have the ability to show payers, ‘Yes, I can measure this and I can show how effective we are, I think potentially that will become a motivating movement with mental health providers in general," Roots said.
Learnings from Veterans Affairs providers
One standout national leader in the implementation of MBC is the Department of Veterans Affairs (VA). In 2016, the agency announced the launch of a national initiative to establish a standard of care in VA health using MBC principles.
The initiative partners with the Office of Mental Health and Suicide Prevention’s leadership, other VHA offices and the healthcare industry to provide consultation, education and support for the implementation of MBC, a VA spokesperson told Fierce Healthcare.
VA policy mandates the use of MBC in three of its mental health programs: substance use disorder, mental health residential rehab and PTSD. The Joint Commission, meanwhile, requires MBC in five VA programs, the spokesperson said.
Currently, 100% of VA facilities participate in MBC. More than 14.8 million mental health patient-reported outcome measures have been administered to veterans thus far. In a mental health provider survey for fiscal year 2022, three-quarters of providers agreed that such measures are valuable for patient care.
The VA believes digital applications can enhance the uptake of MBC, the spokesperson said. The agency has created apps that integrate into the EHR to facilitate the collection of such data over time and to share insights visually with veterans.
Frameworks for the future
Wright is hearing more discussion of measurement-based care in a variety of healthcare settings and believes the industry is moving in the right direction. “It is a potential niche area for technology companies to move into that isn’t saturated yet,” Wright said.
Already, budding and more established companies from Blueprint to Mirah have come on the scene. In October, Blueprint put out a framework to track quality improvement over time, consisting of effectiveness and efficiency with a 100-point quality composite score for outcomes.
The APA currently has a workgroup developing professional practice guidelines for providers to understand MBC, which Wright anticipates being published around February 2025. Meanwhile, the Patient-Reported Outcomes Measurement Information System (PROMIS) is free and publicly available online, offering clinicians valid measures and shortened tests to assess patient wellbeing.
“I think that over time, consumers of mental health are going to get savvier,” Roots said, adding they will want to know if the time they are investing in treatment is actually effective. “Consumer-driven change can really be lasting.”