Implementation of Measurement Based Care in the Context of Telemedicine: Qualitative Study (Preprint)

BACKGROUND The Measurement Based Care (MBC) in Mental Health (MH) Initiative launched by the Department of Veterans Affairs (VA) in 2016 is an example of an evidence-based practice that uses patient-reported outcome measures (PROMs) to improve patient outcomes. Acceptance of MBC among VA providers is relatively high, though utilization is low and varies by discipline. Health information technologies might afford opportunities to address some of the barriers related to uptake of MBC. OBJECTIVE This manuscript reports on an implementation effort to integrate MBC into clinical telehealth practice using e-health solutions. METHODS Qualitative data were generated from 22 semi-structured interviews with psychiatrists (n = 4), psychologists (n=3), social workers (n=3), nurses (n=6), a pharmacist (n=1), and administrative staff (n=5) who provide telemental health care through a community-based outpatient clinic in the rural Midwestern United States. The interviews were conducted during the pilot phase of an implementation initiative to increase adoption of MBC by revising clinic workflows to integrate the use of e-health technologies. Data were analyzed using thematic analysis. RESULTS Time burden and workflow issues were the most common barrier to provider adoption of MBC; sharing and reviewing pencil and paper measures and results in the same room was no longer possible in novel telehealth workflows necessitated by the COVID-19 pandemic. Providers voiced concerns about how long it would take to adequately score, interpret, share, and document the PROMs during the medical visit. Concerns about time might also correspond to a gap in providers’ familiarity with these assessments, greater comfort in assessing symptoms through clinical interviews, and being accustomed to using the assessments as screening tools more so than longitudinal outcome measures. Providers were also uncertain about the recommended timing and frequency of assessments, what was most appropriate for their subspecialty, and how to balance all of this in the context of team-based care, where providers often share patients. Capacities associated with e-health technologies may address workflow concerns and promote providers’ understanding of the measures as tracking tools. CONCLUSIONS The need to use limited appointment time well is top of mind for telemental health providers. e-Health technologies provided operative supports that protect time in appointments by shifting when and how PROMs are collected. Bolstering providers’ familiarity with how to use PROMs may impact providers’ buy-in by encouraging them to reconsider how sharing and acting on PROMs could be time well spent.