Improving Care Through Remote Tracking of Patient-Reported Symptoms

Integrated care approaches and mental health technology continue to innovate as we strive to increase access to effective mental health care and advance care delivery. This month’s author, Denise Chang, M.D., discusses the benefits and challenges of integrating electronic patient health questionnaires into electronic health records. —Jürgen Unützer, M.D., M.P.H.

To provide high-quality, patient-centered care, especially psychiatric care, we rely on patient-reported outcomes (PROs), which are data reported directly by patients about their health and symptoms. The growing measurement of PROs has led to further interest in directly entering PROs into the electronic health record (EHR). As we experience an increasing reliance on EHRs to encapsulate patient data, the opportunity to integrate PROs into the medical record could lead to improved patient engagement and enhanced clinical efficiencies.

Nowadays, EHR platforms often go beyond just containing the medical and clinical treatment histories of patients. They facilitate communication between providers and staff, and some systems even allow for direct communication between patients and providers. One way of obtaining PROs electronically is through online patient portals. Engaging patients outside the care setting using patient portals allows remote clinical monitoring. However, little evidence exists to guide care processes and incorporate appropriate clinical follow-up when using the portal.

Integrating PROs into EHRs aligns with health system goals of improved care for patients and populations, especially for a chronic condition like depression. A model for this is the nine-item Patient Health Questionnaire (PHQ-9), a validated instrument for depression screening and symptom tracking. The PHQ-9 is an example of a PRO measure that is growing in clinical use due to increased population-level depression screening and also in its use to support measurement-based care. At the patient level, using the PHQ-9 can help inform the care team when a patient with depression is not improving and when a change in the treatment plan is needed. This type of measurement-based approach can also be used to evaluate populations of patients. For example, using the PHQ-9 can help teams focus on doing “treatment-to-target” for a provider’s panel of depressed patients, thus allowing for a systematic monitoring approach. The direct entry of PRO measures like the PHQ-9 into the health record allows for visualization of both patient-level progress and aggregate population-level data, which is essential to any population-health improvement effort.

There have been various initiatives to implement an electronic PHQ (ePHQ) for both screening and management of patients with depression. Making the PHQ-9 available via the patient portal allows for patients to fill out this questionnaire online ahead of a clinical visit, which may increase the likelihood of capturing this information more reliably in addition to saving time during the office visit. Moreover, use of the ePHQ increases the likelihood of obtaining necessary PHQ measures for quality metrics, thus increasing the chances of being successful in meeting an institution’s performance goals.

Despite the potential benefits, a pilot implementation of ePHQ functionality at the University of Washington School of Medicine has highlighted several critical workflow and communication considerations related to depression screening and management in the portal. Feedback from providers emphasized the need for clearly defined roles and clinical protocols to respond to ePHQ submissions, particularly for high-risk responses. Specifically, providers stated they favor having tools within the EHR to support clinical decision making when responding to patient-reported suicidal ideation. Having the ePHQ along with clinical decision-support tools within the EHR will facilitate clear communication among providers and staff regarding high-risk patients and help ensure the highest quality of care.

The integration of PROs into the EHR will advance care delivery through quality improvement initiatives and population health efforts. However, to realize the full potential of something like the ePHQ, further research is needed to identify best practices for responding to high-risk comments in electronically submitted patient information. After best practices are established, it will be essential to incorporate them into standard protocols and clinical workflows and to build decision-support tools that are readily accessible in the EHR. These steps could serve to improve patient safety and quality of care, reduce risk, enhance clinical efficiencies and communication, and ultimately support high-quality patient-centered care. ■