The era of evidence-based best practices has arrived, and psychiatry needs to get on board.
Imagine treating patients with hypertension. Vital signs and laboratory tests from prior visits inform decisions to prescribe specific medications, dosing regimens, and other interventions. When patients come for follow-up, along with gathering subjective information and updating physical examination data, one obtains additional objective measurements. These data guide further decisions and are vital to tracking treatment responses.
What vital signs do we use in psychiatry? The era of evidence-based best practices has arrived, and psychiatry needs to get on board. Most psychiatric conditions are chronic illnesses and bear similarities to hypertension, diabetes, and other general medical diseases. However, psychiatric treatment is frequently centered on subjective responses to inquiry and clinical observations that too often are not rooted in, nor systematically compared with, evidence-based guidelines.
Effective tools exist to objectively measure responses to treatment, yet their routine use in psychiatry remains surprisingly limited. The adoption of outcomes measures in other specialties has resulted in reduced morbidity and mortality from a wide range of conditions including diabetes, stroke, heart disease, and many cancers. With the implementation of the MACRA payment reforms, reimbursement will increasingly be linked to physician reporting of outcomes measures. How can psychiatrists provide consistent, high-quality care without using the full complement of available tools? Why would we?
In psychiatry, measurement-based care has been defined as the systematic use of validated measures to monitor patient progress and directly inform care decisions. Evidence supports the effectiveness of measurement-based care in reducing time to treatment response, time to remission of symptoms, and treatment dropout. However, a recent Kennedy Forum issue brief indicates that fewer than 20% of psychiatrists consistently use measurement-based care in their treatment decisions.1
The adoption of outcomes measures in other specialties has resulted in reduced morbidity and mortality from a wide range of conditions including diabetes, stroke, heart disease, and many cancers.
What are the barriers to adopting measurement-based care into routine psychiatric care? The literature has reported a range of issues, from the practical side of workflow integration, to philosophical disagreement, especially the belief that such practices interfere with the therapeutic relationship.2,3
New technology, known as measurement feedback systems (MFS), can overcome many of the practical workflow barriers. Today’s MFS software can automatically assign patient-reported outcome measures (PROMs) based on diagnosis. These scores are collected and are available at the time of the visit, giving clinicians immediate access to actionable data. Many of these systems can be integrated directly into electronic health records, creating a seamless flow of data and documentation. Perhaps more than other specialties, given the tendency for some psychiatric practices to lack or utilize relatively fewer support staff, psychiatric providers may depend on these systems to track outcomes, while reducing administrative burden and enhancing quality of care.
Although many quality improvement initiatives elicit negative reactions from providers, the use of MFS may actually improve our capacity to connect with, understand, and support patients. The ability to monitor a patient between visits to detect changing symptoms or lack of response to treatment can provide valuable data in a timely way. By having immediate access to PROMs, the “vital signs” of our practice, before meeting with patients, better outcomes can be obtained in more efficient ways. With serially validated PROMs, we can minimize the time currently spent teasing out symptom criteria and reallocate this time to healing through human connection. In this way, the use of such measures complements traditional methods of psychiatric practice, rather than being a mechanized and impersonal substitute for compassionate and caring human contact.
Successful incorporation of MFS-derived outcomes measures into routine practice will likely depend on adopting a new language for such measures. Terms such as “measurement-based care” conjure up images of assembly lines and sterile transactions. The less tangible benefits, especially if derived from effective use of MFS, are completely misunderstood. When these measures are integrated directly into the electronic health record, the therapeutic alliance may actually be enhanced. I routinely share measurement results with my patients and reflect on how the data correlate with their subjective experiences. This has increased patients’ engagement in their care and has ensured a better understanding of their experiences.
The FDA defines “personalized medicine” as collecting objective information about patients to tailor treatment more specifically to their individual characteristics, needs, and preferences. I prefer the term “relationship-based care” for this form of personalized medicine in psychiatry.
It is time for psychiatry to adopt the treat-to-target model that has led to significant reductions in morbidity and mortality in other medical specialties. Measurement-based care will help accomplish that goal. However, while I encourage psychiatry to focus on objective data, we must recognize the less tangible benefits of this practice. A practical, data-driven approach can contribute to significant additional benefits by maximizing the time we devote to meaningful relationships with our patients-the value of which may be immeasurable.
Dr. Black is Assistant Professor of Psychiatry; Quality Medical Director; Director, Performance Improvement Education; Lead, Implementation of Measurement-Based Care, Outpatient Psychiatry Clinics, Oregon Health & Science University, Portland.
Dr. Black reports no conflicts of interest concerning the subject matter of this article.
1. Fortney J, Sladek R, UnÃ¼tzer J, et al. Fixing behavioral health care in America: A national call for measurement-based care in the delivery of behavioral health services. The Kennedy Forum; 2015. http://thekennedyforum-dot-org.s3.amazonaws.com/documents/KennedyForum-MeasurementBasedCare_2.pdf. Accessed October 12, 2017.
2. Scott K, Lewis CC. Using measurement-based care to enhance any treatment. Cogn Behav Pract. 2015;22:49-59.
3. Hamilton JD, Bickman L. A measurement feedback system (MFS) is necessary to improve mental health outcomes. J Am Acad Child Adolesc Psychiatry. 2008;47:1114-1119.