Friday, April 13, 2012

Stage 2 MU: Universal Depression Screening?

In Clinical Psychiatry News yesterday, I wrote a column entitled, "Effect on Psychiatry of Stage 2 Meaningful Use," where I focused primarily on the proposal that all "meaningful EHR users" must collect and report 12 clinical quality measures or CQMs. This is not to be confused with the objectives that must also be achieved. Both the objectives and the measures have core items and menu items. The core ones are mandatory (unless one meets exclusion criteria) and the menu ones are selectives (eg, one must be chosen from a list of options).

In the column, I listed the proposed core CQMs (as listed in Table 6 of the Notice of Proposed Rule Making or NPRM) and focused particularly on one of the proposed CQMs, depression screening. Here is the proposed list for Stage 2:

  • receiving consultant reports
  • functional status assessments for patients with complex chronic conditions
  • controlled hypertension
  • medication reconciliation
  • use of high risk meds in the elderly
  • therapeutic drug monitoring
  • antithrombotic use in ischemic vascular disease
  • obesity screening and counseling in kids
  • tobacco use screening in adults
  • cholesterol screening in adults
  • depression screening for ages 12 and up

[For a refresher on Stage 1, this article should be helpful.]
CMS actually proposed two possible schemes for reporting these measures. One scheme -- called 1a -- is to select 12 measures from a larger list of 125 options in Table 8 of the NPRM, with at least one from each of 6 domains. The other -- called 1b -- is to report on all 11 of the Table 6 measures (listed above) and 1 from Table 8. The former scheme makes more sense for most specialists, especially psychiatrists, because it maintains flexibility and does not force us to report on things like cholesterol screening and antithrombotic use, both of which are most likely being addressed by a patient's PCP (primary care physician). If one instead reports CQMs via the Medicare Physician Quality Reporting System's EHR Reporting Option, then one can skip the above two schemes (at least, that's how I read it).

This Table 8 list of 125 clinical quality measures is the proposed list, not the final list that will likely be a subset of these based on public comments. Out of this long list, I list below those CQMs that seem to be most relevant to Psychiatry, while being sure to include at least one measure from each domain.

Initiation & Engagement of Alcohol & Drug Treatment
Clinical Process/ Effectiveness
Medication Reconciliation
Patient Safety
Major Depression: Diagnostic Evaluation
Clinical Process/ Effectiveness
Major Depression: Suicide Risk Assessment
Clinical Process/ Effectiveness
Anti-depressant Medication Management
Clinical Process/ Effectiveness
ADHD: Follow-Up Care for Children Prescribed ADHD Medication
Clinical Process/ Effectiveness
Mood disorders: Appraisal drug & alcohol use
Clinical Process/ Effectiveness
Bipolar Disorder: Monitoring change in level-of-functioning
Clinical Process/ Effectiveness
Screening for Clinical Depression
Population/ Public Health
Documentation of Current Medications in the Medical Record
Patient Safety
Depression Remission at Six Months
Clinical Process/ Effectiveness
Depression Remission at Twelve Months
Clinical Process/ Effectiveness
Depression Utilization of the PHQ-9 Tool
Clinical Process/ Effectiveness
Child & Adolescent Major Depression: Suicide Risk Assessment
Patient Safety
Dementia: Staging of Dementia
Clinical Process/ Effectiveness
Dementia: Cognitive Assessment
Clinical Process/ Effectiveness
Dementia: Functional Status Assessment
Patient and Family Engagement
Dementia: Counseling Regarding Safety Concerns
Patient and Family Engagement
Dementia: Caregiver Education and Support
Patient and Family Engagement
Dementia: Counseling Regarding Risks of Driving
Patient Safety
Closing the referral loop: receipt of specialist report
Care Coordination
Adverse Drug Event Prevention: Therapeutic drug monitoring
Patient Safety

So, if the 1b proposal is chosen by CMS, psychiatrists will have to report on cholesterol and anticoagulants, however this will also result in near-universal depression screening. This would likely result in a lot more referrals to mental health specialists when patients are found to score positively on the screening tool (note that any standardized screening tool is acceptable, such as the BDI, GDS, PHQ-9, and M3), resulting in improvements in morbidity and reductions in costs associated with undiagnosed and untreated depression.

But, it is also likely to result in more PCPs, pediatricians, and OB-GYNs managing mild and moderate depression. Unless they also screen for bipolar disorder, a certain percent of these people -- who have undiagnosed bipolar disorder -- will be placed on antidepressants and be harmed from induction of mania, hypomania, or a mixed state by the antidepressant. If this 1b proposal is chosen, we will need to ensure that PCPs know how to screen for bipolar disorder, and that they are able to recognize mania or hypomania induced by an antidepressant.

If the 1a proposal is chosen, then providers will be able to pick and choose which of the Table 8 CQMs (at least one from each domain) is chosen. While this will be preferable because specialists won't have to report on measures that they rarely address, this path will NOT result in widespread screening of depression, as I expect providers will pick those measures that they already record in most patients currently.

I must say that I am torn between the two options, as I would like to have my cake and eat it, too.

Please comment on your thoughts about this. Also, let CMS know your thoughts by providing public comment prior to May 7 at this page.