nView recently hosted "Impact of Outcome Measurement in Mental Healthcare: A Panel Discussion." This webinar, now available as an on-demand recording, brought together behavioral health experts for a discussion about outcome measurement and measurement-based care and the role healthcare providers can and should play in behavioral healthcare. The panelists were Dr. Jennifer Birdsall, chief clinical officer for CHE Behavioral Health Services, and Dr. Joseph Shonkwiler, healthcare and life sciences business development lead for Amazon Web Services (AWS). The program was hosted by nView Health and moderated by Dr. Tom Young, a board-certified family physician, and chief medical officer, and founder of nView.
The following is an excerpt from the webinar that provides the panelists' responses to the first set of questions posed by Dr. Young. It has been edited for length and clarity.
Q: How do you define measurement-based care?
Jennifer Birdsall (JB): I think the definition is fairly simple. If you were to Google a definition for measurement-based care (MBC), I think most definitions that come up would say something about it being a systematic evaluation of symptoms or some type of outcome to inform your treatment planning. I will say, as a clinician, that when I talk about MBC to my team and colleagues, I like to talk about it in the inverse. If we're collecting data, there needs to be a reason. If we're collecting data just to collect it, there's no value in it. It's a waste of resources and time. We're collecting data to inform care.
I like to define MBC as the practice of basing clinical care on data. So, the exact same definition I provided initially, but the opposite. I think a lot of times when you look at the definition, or when we talk about the definition, it may include some version of routine. That's key. You'll look at differences between measurement-based care and similar words like "monitoring." That's what we used to do.
In my organization, we performed monitoring and we would do what a lot of organizations do, which is a screening at baseline at the initial encounter. Then at maybe every 90 days or quarterly, we would update the treatment plan. That's not as useful to inform real-time decisions about a care plan. The ultimate goal when we talk about the definition (of MBC) is that we're going to inform practice in real-time to improve outcomes. That increased frequency is really important as well.
The last thing I talk about in my organization is oftentimes, you'll see the definition talk about monitoring symptoms. Usually part of the measurement-based care is symptoms. But there are other things I think are important. As we talk about measurement today, and we think about specifying those measures so they're useful for a population and setting, it probably includes symptoms. But it may also include other types of measurement like therapeutic alliance or high-level matters like functioning or life satisfaction. Or if you are working with a patient population and trying to encourage behavioral change, you might want to do some stages of change. We want to consider those kinds of measurements as well.
That gets us back to the core definition. We're using standardized measurement to inform care, but then I like to tack on all those caveats to really inform the practice.
Q: What roles do data acquisition and data transformation play in measurement-based care?
Joseph Shonkwiler (JS): This is basically where the rubber hits the road on the data side. We're collecting all that data. Then it's a question of how does it change management? How does it actually inform the care that patients and others are getting across the spectrum? I think that's the real power of MBC.
On the value-based care side, there's a lot of overlap. The concept of value sounds "squishier" than it is. There are measurements to it concerning what you're getting for what you're paying and how that informs the pathway of care that a person receives and a clinician delivers. I see MBC in a similar frame.
In terms of data acquisition, monitoring and other standardized methods, they are all part of it, whether it's passive or active in terms of actively collecting the data or passively collecting it from sensors, wearables or other means. But I can't speak enough about circling back and using that data to actually inform how you care for the patient in whatever setting you're in. Without that, the data just exists in the abstract.
At AWS, we like to talk about removing the undifferentiated, heavy lifting for companies all over the world. The setting up of servers and databases is something we like to do. But as a physician and somebody who works with startups, investors and folks who really care about getting the outcomes in the space, I think one of the most crucial steps is what happens after that setting up is completed. That's the differentiated, heavy lifting folks are doing in terms of making that data usable and informing care pathways.
Q: How do we incorporate measurement-based care into practices? How do we make that data inform practice?
JB: I think that's where technology comes in. Digital solutions are really important. How we're currently tracking patients in our practice, and we're in the midst of shifting this now through a partnership with nView, is we're doing mostly 90-day tracking. That's the minimum requirement. Providers can do more, but most don't. They do what the organization dictates at that bare minimum right now.
Providers are administering that as part of their updated treatment plans. There's a burden on the provider. That's not a bad way to do it, but it leads to more barriers to delivering more frequent administration, which is what we need — that routine monitoring. It may be daily if there's a severity level or unique symptom that you want to monitor with more consistency to inform your care.
When I think about technology solutions, that's where you can eliminate those barriers; eliminate the burdens. Technology can make things very systematic and streamlined. I like technology that's customizable. For my patients, typically there are multiple measures I want to look at. When we think about measurement-based care, it doesn't make sense to have one depression measure across the whole clinic where that might not even be the right measure for my patient who has a schizoaffective disorder.
With multiple measures, we can determine the appropriate frequency. Then that technology can help automate the tracking. Then in terms of collecting that data back, the technology can push information to the clinician in real-time. But the data is not useful if the providers don't understand it and they can't use it to take action. It must be actionable. I read something that said MBC provides "actionable intelligence." I like that phrase because measuring doesn't matter if we're not using the data effectively to make informed decisions and get the outcomes we want.
I see what we're doing in my organization really out of necessity. The technology is huge because it provides that systematic, streamlined, and automated approach. We eliminate all those barriers that come up with manual administration.
Q: What do we need to be doing with the data we're gathering? How do we make it "play nice" in the clinical world?
JS: Words like interoperability and democratization of data access are thrown around so much on the technology side, but they have real meaning. We like to think that we have a role to play in breaking down the barrier of siloed data. How do you create a common backbone such that that data is accessible and reachable with a bunch of different data sources? Whether it's claims data, lab data, whatever that looks like — there are so many different ways to do it. We've seen that desire among the provider groups across the spectrum to have access to that data.
This has caused a shift in the way we've approached it. Last summer, we announced an effort called "AWS for Health" which is solutions-focused. A lot of those are data solutions. When I say solutions-focused, it's going beyond just the standard building blocks of a technology stack. Traditionally, AWS has been involved in provisioning server space, databases, or whatever that "Lego brick" element is. We're moving up the stack in providing access to solution sets to improve collaboration; to unlock the potential of healthcare data; to actually reach all those patient-centered and personalized health goals that so many folks are now putting on the board for 2022 and beyond. Those solutions are important.
JB: I've been thinking about these issues a lot: the data we want to collect, the outcome measures we want to use and how we want to use them, and why. For me, I'm in a clinical leadership position, so I think about it in two categories. One is the data we're going to push to the providers and the clients because of the need to be collaborative. Whether or not clients can see it on their patient portal or access it another way or whether the provider's talking to them about it and saying things like, "Hey, I looked at this particular measure. I see your symptoms getting worse. Let's talk about it. I want to talk to you about what's going on and think about some changes" — it's collaborative. You have the patient and the provider working together and getting real-time data.
Then I think about the aggregate data to inform quality improvements within the organization based on that data. Right now, I'm focused on clinical, though I think it's important that you include claims data and other measures that drive decisions.
For the clinician and their client, I think about it in multiple ways. There are things like the actual measurements that get pushed in the unique session. For example, the depression measure. We can look at it in total, but we also want to look at the unique items. A client might be reporting sleep disturbance. Perhaps that's never been something they brought up before and they didn't talk about in session. That's important to know. Or perhaps it's suicidality. There are other unique measures and unique symptoms. We can say if there are certain items mentioned, we want them to be flagged right away. Your client answered positively to this, so now you know if it's something like suicidality. There are real-time alerts that can be sent to the clinician. I also want to see something where they can see graphs over time so they can track changes. We want to be able to push that information to the providers over time.
Then for me, in terms of the clinical data at aggregate, I'm going to now be able to say whether there are providers, based on whatever metrics we choose or threshold we establish, who are not hitting the outcomes we would expect on average. Do they need more training? Do they need more support?
I don't want to make it so we're only looking for people who are underperforming. We also want to know who's excelling; who is an all-star. Maybe I'm going to use them to be a supervisor or a consultant, or figure out what resources they're using, or how they're approaching care. That's important for me, not only from thinking about those improvements but we can also look at it as, "We have really good outcomes for depression and anxiety, but for our patients with substance abuse disorders, we don't. Why is that? Do we need to look at our programming?" Those are really impactful for me as a clinical leader.
Also important for me is the ability to use that data from the business development side for matters like payers, contracts, and rates. I think so much of the industry is moving towards outcome measurement and measurement-based care. We're all competing for clients. We're all competing for clinicians. This is kind of the real world of business. We are going to have to start saying, "Here are our outcomes. Here's how we improve care over X amount of time." This will allow us to really show — whether it's direct to consumers, employers, or referral sources — that we're making these value-based changes. That's where I want to see my organization go. And that's what we're engaging nView to help us.
Q: How important is variation and the reduction of variation for payers?
JS: In my role, I have the privilege of being able to see the whole marketplace across all the players in healthcare — whether that's payers, providers, life science, etc. One of the impacts of the last couple of years that we've been through with COVID-19 has been slightly unexpected. The scenario we're now in is where payers, because they haven't been paying out for the high-cost elective procedures, are in a relatively strong financial position. On the other hand, providers, hospitals, health systems, and others have had already tight margins squeezed even more because of COVID. They're on the other side of the ledger with the high-cost procedures.
Concerning variation, payers are looking for what models, what initiatives, what things can we do to get ahead of variation moving forward. Where there may have been some reticence before, because they were very risk-averse, they now have cash on the books. There's this feeling that we can dig deeper into these models and incentivize the minimization of variation or use of value-based programs. On the other side of that, what we've seen at least on the hospital/health system side is an interest in tackling variation as well for all the same reasons. Now they're trying to do whatever they can to get better at efficiency, optimization, and processes. Addressing variation is a part of those efforts.
That's part of the way the value side and getting to these outcomes via measurement-based care dovetail really nicely with one another. It's really a win, win, win. Looking at powering that process, I'm heartened by what I'm seeing in terms of uptake among payers, among providers, among every segment that's evaluating those transitions.
To watch the recording of "Impact of Outcome Measurement in Mental Healthcare: A Panel Discussion" webinar, click here.
Meet the panelists ...
Jennifer Birdsall, PhD
Chief Clinical Officer, CHE Behavioral Health Services
Dr. Jennifer Birdsall is the chief clinical officer of CHE Behavioral Health Services, a multispecialty clinical group dedicated to increasing access to behavioral and mental health services and to reducing stigma associated with mental health conditions. Behavioral health specialists employed by CHE are assigned to more than 1,000 long-term care facilities in several states, including skilled nursing facilities, community-based adult homes, assisted-living settings, adult day care, and rehabilitation centers. Dr. Birdsall specializes in clinical geropsychology and is a licensed psychologist in the states of California, New York, and Connecticut.
Joseph Shonkwiler, MD, MBA
Healthcare & Life Sciences Business Development Lead, Amazon Web Services
Dr. Joseph Shonkwiler is a physician and MBA with experience in clinical medicine, digital health ventures, business development, health policy, and clinical outcomes research. He now works with healthcare and life science startups and investors on behalf of Amazon Web Services. He previously served as a senior advisor in the U.S. Senate and CEO of a bootstrapped healthcare software startup spun out of the Columbia University Department of Surgery. Most recently, Dr. Shonkwiler was a vice president at Aledade, a venture-backed, tech-enabled healthcare services startup. He is passionate about using technology to improve patient care, health outcomes, and health education.
.Meet the moderator ...
Thomas R. Young, MD
CMO and Founder, nView Health
Dr. Thomas Young, chief medical officer for and founder of nView Health, is a board-certified family physician with more than 35 years of medical experience. He is responsible for working with the nView team of software technology experts and the company's customers and partners to ensure clinical best practices are incorporated into all of nView's work. Dr. Young is a recognized thought leader in consumer-directed healthcare and population health management and is a frequent speaker at behavioral health industry events.