overview of the outcome Tracker stystem

Why Monitor Outcome?

Imagine going to your primary care doctor with a fever and symptoms of an upper respiratory track infection. Your primary care provider puts his or her palm to your forehead and agrees that you feel warm. A course of treatment is recommended, you return in a couple of days, and he or she again feels your forehead and notes that you are cooler. Would you be happy with this approach towards care? Would you continue to see a doctor who evaluated your body temperature in this way? We would not accept this level of care from an internist, family practitioner, or pediatrician, and yet this is the community standard of care provided by most behavioral health clinicians when treating depression, anxiety, and other psychiatric disorders.

To determine the impact of treatment it is necessary to evaluate outcome. In mental health clinical settings this typically is based on unstructured interactions that yield unquantified judgments of progress. This is at variance with other areas of medical care in which outcome is determined, in part, by the change of a numerical value. Body temperature, blood pressure, cholesterol values, blood sugar levels, cardiac ejection fraction, and white blood cell counts are examples of quantifiable variables that are used to evaluate treatment progress. In the mental health field, standardized, quantifiable outcome measures exist for most major psychiatric disorders, yet they are rarely used in routine clinical practice. Thus, to determine the impact of treatment it is not simply a matter of evaluating outcome, but rather a matter of measuring outcome.

The use of standardized scales to measure outcome is consistent with the recent Center for Medicare and Medicaid Services Physician Quality Reporting Initiative, which is intended to increase clinicians’ motivation to systematically evaluate outcome by providing financial incentives to monitor outcome.

What Scales are Included on the OutcomeTracker system?

At the present time Outcome Tracker includes two reliable and validated scales: the Clinically Useful Depression Outcome Scale (CUDOS) and the Clinically Useful Anxiety Outcome Scale (CUXOS) (read more about the CUDOS and CUXOS, including the cutoff scores indicating severity levels).

Over time additional scales will be added to assess anger, drug and alcohol use problems, eating disorders, social phobia, agoraphobia, obsessive compulsive disorder, posttraumatic stress disorder, psychosis, mania/hypomania, pain, and somatic symptoms. Because it takes time (and money) to add scales to the OutcomeTracker system, we decided to make it available for use after the depression and anxiety scales, the two most frequently used scales in our practice, were loaded into the system. Moreover, the research on the reliability and validity of the CUDOS has already been published in peer-reviewed journals (click here for references), and the first large validation study of the CUXOS is currently under review.

How Do Patients Know Which Scales to Complete?

At this time the OutcomeTracker system only includes a depression and anxiety scale. The anxiety scale assesses psychological and somatic symptoms of anxiety, rather than any specific DSM-IV disorder. In the future we will be adding scales for a range of DSM-IV disorders. You should tell patients which measure(s) to complete. Because problems with anxiety and depression co-occur so frequently we have our patients complete both scales.

How Often Do Patients Complete the Scales?

The OutcomeTracker system offers two options regarding the frequency of scale completion. Most commonly, scale completion is linked to the patient’s appointment. The patient (or support staff) enters the date and time of the next appointment, and 48 hours before the appointment a reminder email is sent which asks the patient to complete the scales.

Alternatively, there is a weekly completion option, in which patients receive weekly emails asking them to complete the scales. After logging in, patients are asked select one of these 2 options. You should tell patients which option to select.

How Do I Introduce Patients to the System?

After determining that the patient is a computer user who has internet access and uses email then you should explain the purpose of the system (to measure and track their response to treatment, and to remind them of their appointments). It is helpful to give patients an instruction sheet (click here) for registering on the system. The instruction sheet should include your Provider Identification Number (PIN).

What is the Provider Identification Number?

One method of ensuring security is the use of provider identification numbers (PIN). In this way after patients complete their forms, they will be emailed directly to you.

After you register on OutcomeTracker you will be given a unique PIN. Every provider has a unique PIN. You must provide the PIN to your patients, which they will need when they register. When patients enter this PIN they will be asked to verify that the information is being sent to the correct clinician. Patients will not be given your email address, they only need your PIN number.

How does the Appointment Reminder Function Work?

The OutcomeTracker appointment reminder function requires the patient to enter the date and time of their appointment into the system. Then, 48 hours before the appointment, the patient will receive an email alerting them to the appointment, and asking them to complete the CUDOS and CUXOS.

How Does the System Work (from the patient perspective)?

1. After patients register, they are asked to read a HIPAA statement. OutcomeTracker is a secure, encrypted, site that is HIPAA compliant. Patients must acknowledge having read the HIPAA statement before they can proceed.
2. Patient enters the PIN that you provided.
3. Patient is asked to confirm that you are their treating clinician.
4. Patient enters the date and time of their next appointment
5. Patient is asked if they want to complete the scale every week until their appointment, or 48 hours before the appointment.
6. 48 hours before their appointment they receive an email reminding them of the appointment, and asking them to complete the scales. You should tell patients whether you want them to complete the depression scale, the anxiety scale, or both.
7. After completing the scales, the patient receives notice that the scales will be sent to you on the day of the appointment. Thus, patients will not assume that you will see the responses a couple of days before the appointment.
8. You receive an email informing you that the scales have been completed.

How Does the System Work (from the provider perspective)?

After a patient completes the OutcomeTracker scales, the provider receives an email indicating that a scale has been completed. For confidentiality reasons the email does not identify the patient’s name in the sender line. The email contains a link to OutcomeTracker site. After logging in using your password, you will be brought to the patient’s completed form (which can then be printed).

Is the System Secure, Confidential and HIPAA Compliant?

In a single word, yes.

The Outcome Tracker website is a secure, encrypted site housed on its own server. Because confidentiality and security is crucial to the success and widespread adoption of a web-based system we briefly describe the precautions taken.

An evaluation of any process or technology for HIPAA compliance must address such compliance with respect to up to 3 relevant “rules”. These rules are the Privacy Rule, the Security Rule, and the Transactions and Code Set Rule. Some of the ways in which these rules were addressed are as follows:

1. With respect to the Privacy Rule, it is necessary to ensure that all health-related information is protected, and that only authorized uses and disclosures of individually identifiable health information are made.
2. Only a patient’s specific doctor (as well as the patient themselves) can see their records.
3. Clinician sign in to the site requires the use of a Provider Identification Number, which is randomly assigned by the system at registration and is unique to each provider. Patients must use this PIN to tie their activity to a particular doctor which serves as an extra layer of protection.
4. Patients cannot accidentally disclose their records, because there is no single patient accessible function that will consolidate all of their data into one atomic record for display.
5. Notices to the provider that a scale has been completed, and reminders to patients of an appointment, that are sent by the system are generic and do not reveal any private data.
6. Physical Security of the system is well exceeded by the server’s location at an offsite data center in one of the finest and most secure facilities of its type in the world.
7. Technical Security of the database and the system software is addressed by using authentication and encryption techniques.