Effect on Psychiatry of Stage 2 Meaningful Use

Tuberculosis used to be much more widespread, often going undiagnosed and untreated. The Public Health community decided to make TB screening a part of routine screening, leaving a tremendous impact on detection and treatment. Now, imagine the same thing for depression.

We know depression is underdiagnosed and undertreated. SAMHSA’s most recent publication on the state of Mental Health (“Mental Health, United States, 2010”) found that the percentage of adults with an episode of major depression over the previous 12 months was between 5.2% to 9.5%, varying from state to state (page 68). The percentage of those individuals actually receiving any treatment statistically increased from 2009 to 2010, going from 64.4% to 68.2% (see data table). This is much higher than I would have thought, but there are still many who go undiagnosed and untreated.

The Center for Medicare and Medicaid Services (CMS) recently published its notice of proposed rule-making (NPRM) for Stage 2 of Meaningful Use. If you don’t know what I’m talking about, you might want to read this article by Drs. Neil Skolnik and Chris Notte first, which discussed what it’s all about (increasing the adoption of certified electronic health records, or EHRs, which are used meaningfully) and introduces the Stage 1 criteria.

I won’t go into all the changes that are made in Stage 2, but I will talk about an aspect that may prove to have a very large impact on the identification and treatment of people with depression. The Stage 2 NPRM tweaks the definition of a “meaningful EHR user” as follows:

We propose to include clinical quality measure reporting as part of the definition of “meaningful EHR user” instead of as a separate meaningful use objective under 42 CFR 495.6.

To be considered compliant with Stage 2 meaningful use, this change requires that eligible providers, or EPs, must collect and report on a core set of “clinical quality measures,” as well as a menu set of clinical quality measures, which I won’t go into here. (Note: this is actually more complicated, as an alternative schema was offered, as well. If you really want to know more, read the NPRM or e-mail me.)
The core CQMs are mandatory and there are 11 of them. These include the following areas:

• 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

Notice that last one. "Percentage of patients aged 12 years and older screened for clinical depression using an age appropriate standardized tool and follow up plan documented."

Let me repeat this. To qualify for financial incentives (and to avoid financial penalties starting in 2015), all your patients age 12 and up must be screened for “clinical depression” annually. This applies to all specialties, so even the ophthalmologists will need to screen their patients. The other side of the coin is that psychiatrists will need to document blood pressures and cholesterol, even if the data are obtained by the PCP. (If you have something to say about these proposed changes, speak up by providing your public comment by May 7.)

This means that many of the people who are not getting identified and treated are likely to be provided care for their depression. Of course, those who don’t ever make it to a provider won’t get screened. But those who do will need to be treated. This means more PCPs managing depression, and more referrals to psychiatrists, psychologists, nurse practitioners and therapists, counselors, and social workers. More antidepressant prescriptions. More psychotherapy.

It will also likely mean more patients getting harmed by treatment. A proportion of these people screening positive for depression will have a bipolar disorder, but screening for bipolar disorder may not be required for people screening positive for depression. There is a CQM in the menu set that includes bipolar screening, but it seems likely that the final set of menu CQMs will not include this option. 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.

There are surely other consequences of this near-universal depression screening. What do you think of these changes? Comment here or over on HITshrink. I'll address other issues about Stage 2 MU in later columns.

—Steven Roy Daviss, M.D., DFAPA

DR. DAVISS is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to HITshrink, he can be found at drdavissATgmail.com, and on the Shrink Rap blog.

Tuberculosis used to be much more widespread, often going undiagnosed and untreated. The Public Health community decided to make TB screening a part of routine screening, leaving a tremendous impact on detection and treatment. Now, imagine the same thing for depression.

We know depression is underdiagnosed and undertreated. SAMHSA’s most recent publication on the state of Mental Health (“Mental Health, United States, 2010”) found that the percentage of adults with an episode of major depression over the previous 12 months was between 5.2% to 9.5%, varying from state to state (page 68). The percentage of those individuals actually receiving any treatment statistically increased from 2009 to 2010, going from 64.4% to 68.2% (see data table). This is much higher than I would have thought, but there are still many who go undiagnosed and untreated.

The Center for Medicare and Medicaid Services (CMS) recently published its notice of proposed rule-making (NPRM) for Stage 2 of Meaningful Use. If you don’t know what I’m talking about, you might want to read this article by Drs. Neil Skolnik and Chris Notte first, which discussed what it’s all about (increasing the adoption of certified electronic health records, or EHRs, which are used meaningfully) and introduces the Stage 1 criteria.

I won’t go into all the changes that are made in Stage 2, but I will talk about an aspect that may prove to have a very large impact on the identification and treatment of people with depression. The Stage 2 NPRM tweaks the definition of a “meaningful EHR user” as follows:

We propose to include clinical quality measure reporting as part of the definition of “meaningful EHR user” instead of as a separate meaningful use objective under 42 CFR 495.6.

To be considered compliant with Stage 2 meaningful use, this change requires that eligible providers, or EPs, must collect and report on a core set of “clinical quality measures,” as well as a menu set of clinical quality measures, which I won’t go into here. (Note: this is actually more complicated, as an alternative schema was offered, as well. If you really want to know more, read the NPRM or e-mail me.)
The core CQMs are mandatory and there are 11 of them. These include the following areas:

• 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

Notice that last one. "Percentage of patients aged 12 years and older screened for clinical depression using an age appropriate standardized tool and follow up plan documented."

Let me repeat this. To qualify for financial incentives (and to avoid financial penalties starting in 2015), all your patients age 12 and up must be screened for “clinical depression” annually. This applies to all specialties, so even the ophthalmologists will need to screen their patients. The other side of the coin is that psychiatrists will need to document blood pressures and cholesterol, even if the data are obtained by the PCP. (If you have something to say about these proposed changes, speak up by providing your public comment by May 7.)

This means that many of the people who are not getting identified and treated are likely to be provided care for their depression. Of course, those who don’t ever make it to a provider won’t get screened. But those who do will need to be treated. This means more PCPs managing depression, and more referrals to psychiatrists, psychologists, nurse practitioners and therapists, counselors, and social workers. More antidepressant prescriptions. More psychotherapy.

It will also likely mean more patients getting harmed by treatment. A proportion of these people screening positive for depression will have a bipolar disorder, but screening for bipolar disorder may not be required for people screening positive for depression. There is a CQM in the menu set that includes bipolar screening, but it seems likely that the final set of menu CQMs will not include this option. 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.

There are surely other consequences of this near-universal depression screening. What do you think of these changes? Comment here or over on HITshrink. I'll address other issues about Stage 2 MU in later columns.

—Steven Roy Daviss, M.D., DFAPA

DR. DAVISS is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to HITshrink, he can be found at drdavissATgmail.com, and on the Shrink Rap blog.

Tuberculosis used to be much more widespread, often going undiagnosed and untreated. The Public Health community decided to make TB screening a part of routine screening, leaving a tremendous impact on detection and treatment. Now, imagine the same thing for depression.

We know depression is underdiagnosed and undertreated. SAMHSA’s most recent publication on the state of Mental Health (“Mental Health, United States, 2010”) found that the percentage of adults with an episode of major depression over the previous 12 months was between 5.2% to 9.5%, varying from state to state (page 68). The percentage of those individuals actually receiving any treatment statistically increased from 2009 to 2010, going from 64.4% to 68.2% (see data table). This is much higher than I would have thought, but there are still many who go undiagnosed and untreated.

The Center for Medicare and Medicaid Services (CMS) recently published its notice of proposed rule-making (NPRM) for Stage 2 of Meaningful Use. If you don’t know what I’m talking about, you might want to read this article by Drs. Neil Skolnik and Chris Notte first, which discussed what it’s all about (increasing the adoption of certified electronic health records, or EHRs, which are used meaningfully) and introduces the Stage 1 criteria.

I won’t go into all the changes that are made in Stage 2, but I will talk about an aspect that may prove to have a very large impact on the identification and treatment of people with depression. The Stage 2 NPRM tweaks the definition of a “meaningful EHR user” as follows:

We propose to include clinical quality measure reporting as part of the definition of “meaningful EHR user” instead of as a separate meaningful use objective under 42 CFR 495.6.

To be considered compliant with Stage 2 meaningful use, this change requires that eligible providers, or EPs, must collect and report on a core set of “clinical quality measures,” as well as a menu set of clinical quality measures, which I won’t go into here. (Note: this is actually more complicated, as an alternative schema was offered, as well. If you really want to know more, read the NPRM or e-mail me.)
The core CQMs are mandatory and there are 11 of them. These include the following areas:

• 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

Notice that last one. "Percentage of patients aged 12 years and older screened for clinical depression using an age appropriate standardized tool and follow up plan documented."

Let me repeat this. To qualify for financial incentives (and to avoid financial penalties starting in 2015), all your patients age 12 and up must be screened for “clinical depression” annually. This applies to all specialties, so even the ophthalmologists will need to screen their patients. The other side of the coin is that psychiatrists will need to document blood pressures and cholesterol, even if the data are obtained by the PCP. (If you have something to say about these proposed changes, speak up by providing your public comment by May 7.)

This means that many of the people who are not getting identified and treated are likely to be provided care for their depression. Of course, those who don’t ever make it to a provider won’t get screened. But those who do will need to be treated. This means more PCPs managing depression, and more referrals to psychiatrists, psychologists, nurse practitioners and therapists, counselors, and social workers. More antidepressant prescriptions. More psychotherapy.

It will also likely mean more patients getting harmed by treatment. A proportion of these people screening positive for depression will have a bipolar disorder, but screening for bipolar disorder may not be required for people screening positive for depression. There is a CQM in the menu set that includes bipolar screening, but it seems likely that the final set of menu CQMs will not include this option. 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.

There are surely other consequences of this near-universal depression screening. What do you think of these changes? Comment here or over on HITshrink. I'll address other issues about Stage 2 MU in later columns.

—Steven Roy Daviss, M.D., DFAPA

DR. DAVISS is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to HITshrink, he can be found at drdavissATgmail.com, and on the Shrink Rap blog.