So, Lori, we have a couple of really great questions that have come in. The first one deals with this idea of data collection and whether or not it's considered research. So, one of our viewers writes in that he was tracking vitamin D levels and he received a call from his administrator saying that they couldn't collect data in that kind of structured electronic way because it was considered research. And so, I was wondering if you could comment on how you keep data collection for this purpose in a way that is not falls under the guise of research in terms of what IRBs would be considered with or institutional regulators might be concerned with. Yeah, absolutely. I mean, if the goal when you collect the data is for research, then it's for research and you need to get your proper clearance. But I would, I mean, I always say, compare yourself to primary care. Is getting vital signs and collecting a blood pressure when you go into the clinic, is that research? No, that's patient care. I would imagine, and I'm thinking in this example, that you're probably collecting vitamin D levels because you're concerned about vitamin D levels for your patients. And so, if their vitamin D is low, you want to get them started on supplements and get them the correct treatment. It would be the same if you were collecting their hemoglobin A1c and you decided to increase their metformin based on that. So, it depends on why you're collecting the vitamin D. If your goal is to publish a paper and you have set a hypothesis and you're going forward, got a randomized group or something like that that actually defines research, where you're going to, in some way, publicly share that, then that might fall more into that bucket. But for every day, just wrap your head around, if I was in physical health, would someone be saying this? They wouldn't, if you were just collecting it for patient care purposes. It's also okay to aggregate your data. I want to know what percent of my patients have vitamin D deficiency. Oh my gosh, 32% of my clinic has a vitamin D deficiency. All right, what do I want to do about that? I'm going to have a lunch and learn with the staff. We're going to bring in a specialist and we're going to talk about vitamin D deficiency and the mental health effects of that and see if we can decrease the rate of people that have vitamin D deficiency. That is all clinical care. That is not research. So, it sounds like there's either a misinterpretation or if there is something going on where you do plan to publish this, of course, you would need to get appropriate IRB approval, etc. I think that leads nicely into the next question, which is really around data collection. We actually have two somewhat related questions. One is about the utility of using things like iPads in the waiting room and whether there's been any differences identified in the reliability of information that's collected electronically versus on paper. And then there's a related question about working with EMR vendors to build a population health approach that spans inpatient and outpatient. Any thoughts on those two issues around data collection and kind of electronic systems for doing those things? Yeah, and I really, I mean personally, we had an electronic data collection tool. We handed it to the patients when they walked in and we had them complete all of their screens on that tool. It was automatically transmitted. I think it went from Durango, Colorado up to Denver and back down to us in time for us to actually demonstrate it on a screen to patients. My understanding is there haven't been any concerns, with the exception of we always had our front desk reception, because it was done out front, keep an eye on people. Sometimes they don't understand it. It's not in their language. Might be an older person who's just unfamiliar with electronics and gets frustrated, so I'm not seeing necessarily that we're hearing that it's any different than paper or verbal, but what we had to watch for was literacy, language, age, you know, those sorts of things. But we absolutely used it. People are going to kiosks. And when it gets to the EMR, absolutely insist that it's built in. And what you're actually seeing now is a whole lot of these vendors, Epic, Cerner, whatever they are, they're actually coming in with many of these built in. Now, they built them in before the Kennedy Forum report came out, so I often hand them the Kennedy Forum and say, hey, we need this. But you really, when you're looking at new vendors, absolutely ask. And you can go back to the list we showed on that slide. What are the common metrics, both physical and the psychological metrics, that we want to be tracking? Otherwise, if you don't build it in, you end up putting it in weird places. I had one clinic where we put it in, there was one more spot left in vital signs. It was probably for, I don't know, pulse ox or something. But we ended up putting PHQ-9s over in the vital signs, which probably isn't bad. It popped up every time. But we had to do a workaround. So as much as you can, ask the vendors for this up front in the build. And not only do you want to be able to track it for an individual patient, please ask if you can actually graph it. You saw that graph we had on our screen. Most of them can graph it, but they also have to be able to aggregate it, run a report and aggregate it. And that is often in the population health management tool. So quite a few of them have that population management capability. They have to have it for diabetes and hypertension. Why not have it for depression, anxiety, trauma, and other things? But absolutely ask for that. And many of them, they've already, they saw the writing on the wall, and they're already doing it. We have a question related to workforce. Really two questions. One is, have you seen in your experience that shifting towards measurement-based care puts additional strain on the workforce in terms of providers having their, just kind of summarizing this question, having their clinics silt up with individuals who are sicker, that the acuity of psychiatric or mental health clinics becomes higher because you're keeping more individuals with lower acuity in the primary care setting? I haven't so much seen that yet. And I think it's because measurement-based care is just getting up and running. I don't think that measurement-based care is becoming more prevalent, but really until there's expansion of the reimbursement for the CPT codes for collaborative care. I don't think we're going to really see as much of this shift. But if and when it does happen, I think having that more specialty care in the specialty behavioral health setting, that's where it should be. That's where it is in the rest of medicine. You don't see cardiologists taking care of routine hypertension. You see them taking care of folks that have had heart attacks and strokes and other things. So really thinking about it, as patients become more severe in that setting, that is what we are trained to take care of. Now let's have some tools, some time, and a team. We're really going to have to think about it takes a team to measure or to take care of complex patients. How do we move to team-based care in specialty mental health, just like we have patient- centered medical home in primary care? And that's going to be a shift for us in mental health. But I just personally, as a psychiatrist, would I love to hang on to the easy patients because it makes it easier for me? You know, before the next guy with schizophrenia comes in, sure, that makes my day a little easier, but is that a good use of my time or is that a little bit of a waste of my time, that my primary care colleagues could be doing that while I work someone in with schizophrenia who got out of the hospital last week instead of seeing that person next month. So I think that's a shift for us. We can also use our tools, though, to know when we can let go of a patient and have primary care take over because we're now using a tool to know when that, aka, sicker patient is actually ready to go. They can come into specialty care, get an episode of, let's say, dialectical behavioral therapy, and then they're able to move back to primary care to have their Lexapro refilled. So really that mentality and using our tools for it, I think, is where mental health is going. I think it's where it needs to go because there are too many people not receiving care because we've kind of packed our specialty side of the house with patients with mild conditions who could be treated in primary care or elsewhere. Great. Great. And one final question here, Lori. You know, so many of our attendees here on the SMI Advisor webinars are really frontline clinicians who are doing the work with patients every day. If you could recommend that people who attended this webinar do one thing differently, that they had one key kind of clinical everyday takeaway that they should start implementing tomorrow in their clinic, what would that be? So what we say when people want to start measurement-based care is pick your population, pick your issues. So when I'm in primary care and I say, pick your population, what's your biggest pain point or what's the biggest place where you can have to really follow and track metrics, I'll say, pick a population. They may say, all patients with depression and diabetes, or they may say, we're just going to pick depression and anxiety, or we're just going to pick, I had a clinic that said, we're just going to pick depression and track it. So I would say the number one thing is go back to your clinic and ask yourself, what is the one thing we could do? And I always say, start simple. What is the one thing we can start measuring and tracking to get our feet wet, you know, figure out how to do this, and then we can expand it as we need to. So something as simple as, we're going to do, we're going to start monitoring all of our depressed patients with a PHQ-9, or we're going to start monitoring all of our patients with schizophrenia who are on a second generation of psychotic, all of them we're going to monitor and track them for diabetes and link them to care if they need it. So the number one piece of advice is pick your population, but when you're getting started, make something simple. Don't make it too complicated. You can move into the harder stuff once you kind of get your legs underneath you. That's what we, that's sort of the general advice we got. Some people try to, we're going to do five, it's like, well, start with one or two, and then let's see where that goes. Get it nailed, you know, in your workflow, and then you can expand if you want. You could go to your payers and say, hey, what do you want? Or you could look and say, you know, we already got this, we got to do this. But pick your population is the first rule of measurement-based care. Well, Sage, advice, and Dr. Rainey, thank you so much for joining us today.

data collection

research

Institutional Review Board

patient care

electronic data collection tools