Measurement-Based Care: Innovative Technology to Provide Evidence-Based Practices and Improve Health Outcomes

The abrupt shift in the delivery of behavioral health care due to the coronavirus (COVID-19) pandemic is unparalleled. Plans to enhance behavioral health access through telehealth, scheduled to take years at most organizations, were accomplished in a matter of weeks. This rapid transition to telehealth—defined as “the use of electronic information and telecommunications technologies to support long-distance clinical health care” (HRSA, 2021)—was a remarkable information technology accomplishment driven by patient care needs and financial necessity.

In many states, early implementation of shutdown policies, preparation of hospitals for ICU COVID-19 surges, social-distancing mandates, and relaxed regulations regarding payment for telehealth services were factors that drove this transition. Further, with widespread acceptance of telehealth by providers and patients, it seems unlikely that the delivery of behavioral health will return to its pre-COVID-19 state. However, this will only be achieved if payors continue to provide coverage for expanded services.

Behavioral health organizations and providers must prepare for a new, data-driven care environment to support the ongoing use of telehealth to improve access to care. This transition raises many questions: How may data and technology be utilized to reduce health care disparities? How will behavioral health care delivered via telehealth be evaluated? How will it be determined if care provided via video is equivalent to care delivered in person? Is there an outcome difference between audio and video visits? According to a recent review of the literature, “in most cases, telehealth appeared to be equivalent to in-person care. Telemental health findings indicated that for assessment and treatment for a variety of mental health conditions, outcomes of telemental health were not significantly different from those of in-person care” (Shigekawa, Fix, Corbett, Roby, & Coffman, 2018).

A Role for Measurement-Based Care

Measurement-based care (MBC) is defined as the systematic use of patient-reported data to monitor treatment progress and inform care decisions (Fortney et al., 2017). Research, including more than twenty randomized controlled trials and ten systematic reviews, indicate that MBC outperforms treatment as usual, with benefits found across diverse settings, populations, and disorders (Lewis et al., 2019). In the past, the primary driver to implement MBC has been to improve individual patient care and increase access through population health management. Yet, MBC also has the potential to answer many of the questions previously posed, including the evaluation of health care delivery models through outcomes monitoring. Standardized collection of patient-reported outcomes data could also build the foundation for a clinically focused, real-world behavioral health registry, such as the APA’s PsychPro Registry. On a practical level, MBC provides behavioral health providers with the data needed to monitor and adjust treatment in a variety of settings, including hospitals, treatment centers, and clinics. With studies demonstrating that care is more effective and efficient when augmented with MBC, accrediting bodies, payors, and behavioral health organizations are calling for broad adoption (Black et al., 2020).Behavioral health organizations and providers must prepare for a new, data-driven care environment to support the ongoing use of telehealth to improve access to care.

Improving Patient Outcomes

While the exact mechanism of action is unknown, MBC is thought to improve patient outcomes through a number of factors. First, MBC invites patients to reflect on their symptoms and become more knowledgeable about their conditions. This awareness also allows patients to then more meaningfully engage in shared decision making and treatment planning. Patients often become more aware of symptom fluctuations with improved ability to identify triggers and early warning signs for relapse or recurrence.

Through the systematic use of MBC, providers have access to more objective data to indicate when a change in treatment is indicated. The data can also help identify lack of treatment response or residual symptoms in the case of partial treatment response. This information aids providers in understanding when patients may require more intensive levels of care versus a step-down in care.

MBC can also help providers monitor patients for suicide risk through measures like the PHQ-9 or C-SSRS. MBC may be likened to the vital signs of behavioral health, facilitating the treat-to-target approach that has been successful in many medical specialties.

Using Health Technology to Deliver Measurement-Based Care

Despite MBC’s demonstrated ability to enhance care by expediting improvements and detecting patients whose conditions are deteriorating, it is underused, with less than 20 percent of behavioral health practitioners integrating it into their practice regularly (Jensen-Doss et al, 2018). However, advances in health technology have streamlined the process of MBC for providers. Technology-facilitated MBC automates the process of assigning, administering, scoring, graphing, and documenting the results of patient-reported outcome measures (PROMs). This use of technology has become invaluable in the telehealth setting, where the administration of paper PROMs is no longer an option. Technology allows providers to continue to use the evidence-based practice of MBC across care environments, including telehealth.

Innovative Health Technology for Behavioral Health Providers

As the demand for behavioral health care continues to rise, health care organizations and providers need to find innovative ways to enhance access to and maintain quality of care. The use of behavioral health technology to facilitate diagnostic screening, treatment, and treatment monitoring will be a critical piece of the solution. From supporting triage to the appropriate level of care to providing more effective care, technology-facilitated MBC has the potential to enhance the capacity of our current behavioral health workforce, especially given the current risks of in-person treatment during the COVID-19 pandemic.

There are certainly barriers to technology adoption, and they exist at every level in health care. Yet, we have recently witnessed how quickly health care can shift to ensure the ongoing delivery of high-quality care in a changing care environment. Implementation planning is a critical step in this process. If done well, the use of technology-facilitated MBC may reduce barriers to using evidence-based practices and improve access while collecting data to inform future research and resource allocation. The COVID-19 pandemic has produced a dramatic shift in behavioral health care delivery. The pace of change is unprecedented. We can continue to build on this momentum by embracing the tools and technologies at hand to demonstrate the positive impact on quality and access, and to serve all current and future patients with behavioral health conditions.

References

• Black, W. E., Esposito-Smythers, C., Liu, F. F., Leichtweis, R., Peterson, A. P., & Fagan, C. (2020). Leveraging health information technology to meet the Joint Commission’s standard for measurement-based care: A case study. The Joint Commission Journal on Quality and Patient Safety, 46(6), 353–8.
• Fortney, J. C., Unützer, J., Wrenn, G., Pyne, J. M., Smith, G. R., Schoenbaum, M., & Harbin, H. T. (2017). A tipping point for measurement-based care. Psychiatric Services, 68(2), 179–88.
• Health Resources & Services Administration (HRSA). (2021). Telehealth programs. Retrieved from https://www.hrsa.gov/rural-health/telehealth#:~:text=
• Telehealth%20is%20defined%20as%20the,public%20health%2C%20and%20health%20administration.
• Jensen-Doss, A., Haimes, E. M. B., Smith, A. M., Lyon, A. R., Lewis, C. C., Stanick, C. F., & Hawley, K. M. (2018). Monitoring treatment progress and providing feedback is viewed favorably but rarely used in practice. Administration and Policy in Mental Health, 45(1), 48–61.
• Lewis, C. C., Boyd, M., Puspitasari, A., Navarro, E., Howard, J., Kassab, H., . . . Kroenke, K. (2019). Implementing measurement-based care in behavioral health: A review. JAMA Psychiatry, 76(3), 324–35.
• Shigekawa, E., Fix, M., Corbett, G., Roby, D. H., & Coffman, J. (2018). The current state of telehealth evidence: A rapid review. Health Affairs, 37(12), 1975–82.

Whitney E. Black, MD

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Whitney E. Black, MD, is an assistant professor, Owl Insights advisor, and quality medical director in the department of psychiatry at Oregon Health & Science University.

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