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We sit down with Kevin Ramotar, a clinical psychologist and health care executive, to explore the evolving landscape of mental health care. We dive into the challenges of measuring therapeutic outcomes, the role of technology in improving access and care, and the rise of measurement-informed care. Kevin shares his insights on how this data-driven approach is reshaping patient-provider relationships, enhancing transparency, and delivering better outcomes for patients.

Kevin Ramotar is a clinical psychologist and health care executive.

He discusses the KevinMD article, “Providing clarity in behavioral health: How patients, providers, and payers can benefit from measurement-informed care.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Kevin Ramotar. He’s a clinical psychologist and health care executive. Today’s KevinMD article is “Providing clarity in behavioral health: How patients, providers, and payers can benefit from measurement-informed care.” Kevin, welcome to the show.

Kevin Ramotar: Thank you for having me. Nice to speak to another Kevin.

Kevin Pho: All right, well, thanks for writing. Just tell us a little about your story, journey.

Kevin Ramotar: Yeah, absolutely. So I’m a clinical psychologist, master’s in clinical psych with an emphasis in marriage friendly therapy, and a doctorate in clinical psychology as well. I did my clinical training at Stanford and UC San Diego, ended up staying at UC San Diego for about 10 years as director of quality and patient safety, obviously more on the behavioral health side.

And I just became enamored with quality improvement, just health care patient safety, Lean Six Sigma, and just how we can continually work towards building a perfect system of care for clinician and patients. It’s an aspirational aim of course, but just really obsessed with that.

It’s worth mentioning that before psychology I was really deeply into tech, programming, thought I was going to go into computer science. Did not, clearly, but there was just this intersection between psychology and mental health that was emerging, and this is like 10, 15 years ago, so it was in its infancy. But I was able to be an adviser for about eight different telehealth companies, and I can tell you pre-COVID versus post-COVID, the adoption of digital health was starkly different. Companies doing the same thing pre-COVID were not successful that I was working with, and the ones after COVID were very successful, I think just because the world changed around it. So there was a point where I couldn’t get clinicians to try telehealth before COVID, and now after COVID I couldn’t get them back in the office.

So after leaving the health system after 10 years, I’m now at Rula, formerly known as Path, as the head of clinical care and quality. And Rula is mostly providing telehealth services across all 50 states, strong focus on clinical quality. So a lot of my work has been focused on how do we translate health system clinical quality to a digital health model, that same sense of clinical rigor to telehealth.

Kevin Pho: All right, the KevinMD article, which talks more about that, is titled “Providing clarity in behavioral health: How patients, providers, and payers can benefit from measurement-informed care.” Tell us the events leading up to this article, and for those of you who didn’t get a chance to read this article, tell us about the article itself.

Kevin Ramotar: Yeah, absolutely. So measurement based care simply is as simple as patients completing measures about their symptoms, their experiences, and providers taking that information and using it in session. And I make that very clear, that sometimes people think just obtaining measures is measurement based care, but there’s no utility to it unless the provider is using it.

So where it came from for me was, I’ve seen this become more popular over the years. Measurement based care is not new by any means, I’ve been doing it for years in the health systems, but I’ve seen the attention just skyrocket, especially after COVID and probably to some degree related to payers. But also the research is really robust, that use of measures in treatment can really improve outcomes, help the collaboration, communication between a patient and a provider. So there’s a lot of benefits there.

The thing that motivated me on this was that while not new to the industry, it is newer to providers. We don’t learn about this in school. We’re lucky if some of the training sites we go to even adhere to measurement based care. So you can see providers may look at this with some suspicion, at least psychotherapists. There’s a lack of familiarity, so how do I use this stuff, and just feeling a sense of intrusion. The therapeutic relationship can be this really intimate dyad, that it feels like, oh, now something else here is in the room with us.

And change first of all can’t be measured just by measures, and I wanted to make that very clear too. Change is very multi-dimensional in psychotherapy. But I just wanted to highlight in this article the value of measurement based care for the therapeutic relationship.

One thing that’s very clear is that one of the reasons treatment does not work at times, or why there’s disruption or ruptures in the therapeutic relationship, is because the patient and provider may not have the same goals. And there’s a lot of research on that. And I know it sounds funny, right, you’re working together, but it’s similar to any relationship where we just walk away with a different sense of the problem than the other person. So that happens a lot in therapy.

And measurement based care creates a common language between the patient and provider, right? We can talk about progress in the same way, symptoms in the same way, we can reassess your goals, check in on our relationship. So there’s that place to increase collaboration and communication, but I really just wanted to underscore that as well.

And the last thing I’ll say that I wanted to mention is that throughout my years in the industry, psychotherapy has had sometimes a difficult road in the medical world as well, just for adoption. We know something about psychotherapy works, but it can be opaque compared to other disciplines. So one thing measurement based care allows us to do is to demonstrate outcomes, to show that therapy works. I don’t often like this word, but legitimize the work. It’s like a math problem, you’re just showing your work. And that has allowed payers, the world at large, to say, hey, therapy is a vehicle where change is more likely to happen than not, there are good outcomes.

Kevin Pho: So tell us about some of the common tools that clinicians can use to measure care in the behavioral health world. You mentioned a couple surveys, of course very commonly used, PHQ-9 and GAD-7. So tell us more about these tools themselves.

Kevin Ramotar: Yeah, I think the two common, what the people say the gold standards are, that are widely adopted, are PHQ-9, GAD-7. There’s other measures that I see there, like the PCL for PTSD. People are also using the Columbia suicide scale for risk.

But this is an area that I really think that we have been really transfixed on the PHQ and GAD, and there’s a lot of opportunity here for us to think, those two measures don’t always reflect clinical experience. And you’ll see that providers sometimes push back and say, this doesn’t reflect my patient, right? GAD may kind of over report someone with PTSD and not show change in any sort of rapid fashion.

One thing that I’ve been really recommending is us thinking about, instead of thinking of a set of measures that we give everyone, can we make that more dynamic and think about this person and their condition, what are the measures that match that, right? Someone’s coming in with OCD, could we give them a Y-BOCS? Can we give someone with PTSD a PCL? And then the PHQ and GAD makes sense for a lot of people, but not everyone.

So that’s why sometimes I struggle with that question, because I don’t know if there’s measures that are accepted across the industry, but then I think we also need to move into a place where we’re holding in measures that make sense to individual patients. So personalizing the measures to individual patients, versus a blanket, blunter instrument that we currently have. Which is sort of the easy, rapid approach to implementing measurement based care, but I think true implementation takes it a step further.

Kevin Pho: Sure. So give us an example of how results from these surveys, a story or case study, can positively influence the care physicians and clinicians can give to their patients.

Kevin Ramotar: Absolutely. Well, I can tell you how I’ve used it in the past. So thinking about it as mental health vitals, right? Because clinicians think about, how do I use this in session, how do I weave it into the conversation? That can be challenging. But I think most of us are used to going to care, getting our height and weight done. We don’t think anything of it, maybe we don’t look forward to it.

But the same thing with measures is that if it becomes part of the therapy session, one can just talk about it in the beginning, just as you’re sitting down in the office, as you’re getting comfortable in your chairs, and say, let’s take a look at your mental health vitals. How is your mood doing, how is anxiety doing, how are all these other things that we’ve been talking about doing?

The beauty of that is then it’s not always about the total score, like this person still flagging for maybe a depressed mood. It’s about those individual items too, and each one of those creates a jumping off point. So I don’t know if it’s a specific example enough, but I do think it’s been a wonderful opportunity just to talk about the different ways people are feeling, but also tying it back to the relationship too. Because one thing I do recommend in measurement based care bundles is some sort of measure of working alliance, like how is the therapeutic relationship doing as well.

Kevin Pho: So do we have the room to move in terms of improvements that we could make, not only in the tools that we have but in terms of adoption? Tell us some of the next steps and where we can improve and increase the adoption of measurement based care in behavioral health.

Kevin Ramotar: Yeah, we know that patients are 50 percent more likely to fill out these measures, because there’s two components of measurement based care, right, the patient completing a measure and a provider using it. A provider not using it will lead a patient not to be doing it, because it doesn’t seem very important. But the more you’re talking about these measures, like I said, making it the jumping off point for conversations you’re having, the more our patient sees that, hey, this is something that’s actually very valuable in our session.

Sometimes patients say when they come into session they don’t know what they want to talk about, and that can actually make people very nervous, but measurements give them an opportunity, or these items, to talk about these things. So for one, getting providers to understand that there is a value to this, right? Because there can be the sense that this is something that payers want, or external bodies. And I’m not going to say they don’t benefit from that, and I think it’s important for payers and all of them to see therapy works in order to enable the care, to give people more access.

But the research is very sound, and even in my experience, is that using these tools enhances the therapeutic relationship, the connection between the patient and provider, and has a shared language of progress. So I think it’s about really hitting on the why for clinicians.

And the last thing I mentioned on this too is that even with this influx of this idea of like we need to measure care, clinical judgment is still something we really need to make sure we keep at the center, that clinical intuition. And I think if that’s any sort of takeaway from this for me, it’s like measures are important but so is the clinical judgment. So measures shouldn’t dictate care as much as they should inform care. In fact, we’ve changed to move instead of measurement based care to measurement-informed care for that reason, that the clinician is still working with the patient to figure out the right ways to go. Measures inform that, and sometimes they don’t, and that’s OK.

Kevin Pho: You mentioned in part of your background that you’ve been in an intersection between technology and clinical psychology in your past. So tell us about some of the technological approaches that could better implement these measurement based tools. I’ve heard tools where patients or clients can fill out these questionnaires electronically before they come to a visit, so it increases the adoption rates. Talk about some of the technological advances in increasing the adoption and use of behavioral health measurement tools.

Kevin Ramotar: Yeah, it has to be easy for both the patient and provider. On the provider side we need to educate and help understand again the why, and the how to use it as well, especially if there’s gaps in their knowledge around it.

But what I see a lot is making it easy for, for example, even a patient check-in experience. Again, this is something in medicine we see a lot, right? When I go see my primary care they send me a set of surveys, and I have to complete them. And in the health system I worked at in the past, it was a part of the check-in workflow before you even got to your link to your visit. So it just felt like normal.

So I think if we can make it easy for patients, we could send them reminders to complete these measures, show them their results. Because I think that happens a lot, it’s kind of like when you get labs but you just don’t know your results. And I know we’ve been working to change that as a general industry, but with measures, you want to be able to help patients be able to see it themselves, have their own dashboard. Because it’s not some clinical tool, as long as a provider is talking about it, a patient can have it and see it as well.

And then on the provider side, it’s making it, this is where it gets, I think from a systems perspective, making it easy for the provider to access it. If you’re in something like Epic and you’re aware how many clicks it takes to do everything, right? If you can provide the measures, the results, right there in the provider’s face, no extra clicking. And that’s what at multiple sites I’ve worked at we’ve strived to do. Like, how do we embed it into the documentation, how do we make it very on the side pane of the documentation? We want to make it so the provider doesn’t have to click anymore, because in a time crunch measurements will be the thing that gets lost.

Kevin Pho: So how far are we from that ideal? If we’re talking about low-hanging fruit, what are some immediate steps that we can take as a health system to better adopt these tools, either from a provider point, payer point, patient point? Just give us some low-hanging fruit in terms of what happens next.

Kevin Ramotar: I think what should happen next, especially since we have a lot more power in AI to drive logic here, is, like I was saying earlier, at times there’s just here’s a bundle of measures we give everyone. But I think we have an opportunity not only to systematize the patient experience, that they come in and it’s a part of their normal workflow, but then we start to take a look at the diagnosis with some other fields in the documentation and start to make suggestions of, here’s some measures that we should do instead, right? And this is where you become more dynamic in deploying measures.

So I think from a product standpoint we can get smart, smart administration of the right measures as well. And I think we’re getting closer to that too, because with AI especially, and I’ve been really blown away by how fast things are moving here too, but it doesn’t take deep logic for us to understand what we need to give a patient in this case.

Kevin Pho: We’re talking to Kevin Ramotar. He’s a clinical psychologist and health care executive. Today’s KevinMD article is “Providing clarity in behavioral health: How patients, providers, and payers can benefit from measurement-informed care.” Kevin, as always, we’ll end with some of your take-home messages that you want to leave with the KevinMD audience.

Kevin Ramotar: I mentioned one, but I’ll share with you two. It’s this idea that measurement, and measurement based care and focus on clinical outcomes, is an important aspect of modern clinical practice. We’ve come a long way from our work being ambiguous and mysterious to try to make it more visible and understood. Judgment and intuition is an important part of that equation.

Clinical practice is a science that we need to adhere to, best practices of course, clinical pathways, etc. But there’s an art to it, and I think this is across disciplines too, that is the art of just being human, the art of your judgment, how you’re feeling in that room with people. There’s been times where people are saying something but you’re feeling something different, and you ask a question about how you’re feeling versus what they’re saying, and then there comes this big disclosure that, oh, your feeling was right, they just didn’t want to share something. So I think together, measurement based care and clinical judgment are just a powerful combination.

A personal example of that too, a physician diagnosed my dad’s heart condition on a hunch, right? He ran some tests and he was like, let’s just do this to be safe, I’m not too sure, I just have a feeling that this is a good idea. Ended up finding a pretty rare heart condition and we got the treatment we needed. So I’ve always appreciated that physician going outside the box. I’m sure a clinical pathway said do X and his gut said also do Y, and ultimately we can save lives that way.

Kevin Pho: Kevin, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Kevin Ramotar: Thank you.