Measuring Behavioral Health

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For many medical providers, measuring patients’ health and progress is as easy as doing a blood draw and ordering a lab test. But the mileposts are less concrete for mental health specialists treating issues like depression, anxiety and attention deficit hyperactivity disorder.

“With behavioral health, it’s hard to know how a patient is doing at any given moment,” says Dr. Freda Liu, a psychologist at Seattle Children’s and a researcher in the Center for Child Health, Behavior and Development.

Liu and her colleagues are trying to overcome this by studying whether a systematic way of regularly measuring patients’ symptoms – called routine outcomes monitoring (ROM) – could help providers to assess treatment progress and respond to patients’ needs.

“We think ROM could make it easier to know if treatment is working and make changes when it’s not,” Liu says.

Knowing When to Change Course

Liu and her colleagues in Seattle Children’s Psychiatry and Behavioral Medicine Clinic rolled out a computerized ROM system that patients can log into from any web-enabled device including computer kiosks in clinic waiting rooms. The system collects answers to questions about symptoms and asks patients to rate their relationship with their provider (s) by indicating how strongly they agree with statements like “my therapist understands and respects me” and “my prescriber and I are working toward the same goals.” Then providers can review these answers, see how they change over time, and share the resultswith patients and families.

In her own practice, Liu logs on to the system before each appointment to see how a patient is doing according to their self- and parent-reported symptoms.

“Without ROM, it might take a few visits before you know something isn’t working,” Liu says. “Clinicians are actually quite bad at guessing which of our patients are not doing well when relying on clinical judgment alone; ROM gives us immediate feedback, to help decide when to change course.”

ROM can also help patients understand their symptoms and progress compare to peers. “Patients can see their results graphed against norms of same-age peers, so that I can say, ‘the rate of anxiety symptoms you are reporting is a lot like those of other kids your ages who are not being seen in a clinic, which tells me that you’ve made great progress toward recovery and perhaps it’s time to wrap up therapy,’” Liu says.

Establishing a Baseline

Liu is investigating how providers monitored patients’ symptoms and progress before ROM was implemented. Her team is combing through providers’ clinical notes and chronicling any time they mentioned using measurements in treatment. These results will be compared to providers’ documented use of measures after ROM was put in place.

“It’s a huge undertaking but it will let us see whether ROM influences providers’ clinical practice and treatment decisions as well as patients’ participation,” Liu says.

Addressing Disparities

Rolling out quality improvement (QI) strategies like ROM is meant to improve care for all patients and families. But disparities will emerge if patients and families do not have equal access to the QI intervention. This can be especially problematic with web-based tools if the patient population does not have equal access to technology or the Internet.

Part of Liu’s research addresses these pressing issues in the context of web-based ROM. Currently, she is studying the feasibility of implementing ROM with diverse patients and families at Odessa Brown Children’s Clinic. This work is funded by Seattle Children’s Center for Diversity and Health Equity.

Liu plans to apply for a National Institutes of Health career development (K) award – a grant that helps young investigators establish their research careers – to study how web-based ROM can be leveraged to reduce pediatric mental health disparities. She hypothesizes that ROM will help improve patient-provider communication and make patients and families more engaged in treatment, which is linked to improved outcomes. Moreover, ensuring equal access to ROM for all patients/families could reduce the mental health are gap between mainstream patients and families and those in underserved populations.

Looking ahead, Liu believes that web-based ROM would not only improve the quality of care we provide to all patients, but also make it easier to study new clinical practices and approaches.

“We could try something new and then quickly see whether it improves outcomes,” Liu says. “It can be a really powerful tool.”