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Behavioral Health

Behavioral Health Clinical Quality Measures

Technical Expert Panel (TEP) Project Overview

The Office of the National Coordinator for Health Information Technology (ONC) and the Substance Abuse and Mental Health Services Administration (SAMHSA) supported a federal cross-agency initiative regarding Behavioral Health Clinical Quality Measures (BH CQMs). The project, which concluded on September 30, 2012, facilitated the development of a portfolio of BH CQMs for potential inclusion in the Centers for Medicare & Medicaid (CMS) Electronic Health Record (EHR) Incentive Program for Stage 2 and/or Stage 3 of Meaningful Use and developed recommendations for future CQM development across six behavioral health domains (depression, suicide, drug use, alcohol use, trauma, and autism).

The project was comprised of two phases:

  1. Electronic specification (eSpecification) of prioritized BH CQMs under consideration for future stages of the Meaningful Use program.
  2. Development and facilitation of a Technical Expert Panel (TEP) of public and private BH specialists for the purpose of identifying and prioritizing recommendations for future development of BH-related CQMs.

eSpecification phase

The first phase involved e-specification of 10 clinical quality measures related to behavioral health (see table 1). Measures included both National Quality Forum (NQF) endorsed measures and measures that have been submitted for endorsement for which e-specifications were needed for use in EHRs.

Table 1. Final Prioritized eSpecified List of Behavioral Health Clinical Quality Measures

Bipolar Disorder (BD and Major Depression (MD): Appraisal for alcohol or chemical substance use Alcohol 1 EP 0110 CQAIMH
BBD and MD: Assessment for Manic or hypomanic behaviors Depression 1 EP 0109 CQAIMH
BD: Suicide Risk Assessment Suicide 1 EP 0111 CQAIMH
Maternal Depression Screening Depression 2 EP 1401 NCQA
Follow-up after Hospitalization for Mental Illness Depression 1 EP 0576 NCQA
Risky behavior assessment or counseling by age 13 – Alcohol, Tobacco, Substance Abuse, Sexual Activity Substance Use Disorder (SUD) 1 EP 1406 NCQA
Risky behavior assessment or counseling by age 18– Alcohol, Tobacco, Substance Abuse, Sexual Activity (SUD) 1 EP 1507 NCQA
Alcohol Screening Alcohol 1 EH 1661 TJC
Alcohol Brief Intervention Alcohol 1 EH 1663 TJC
Bipolar antimanic agent Depression 2 EP 0580 RHI

*0110 and 1401 were included in the Final Rule of Stage 2 MU

Technical Expert Panel

The second phase of the project involved convening a TEP composed of public and private sector BH experts, representing the clinical domains of Alcohol Use, Autism, Depression, Drug Use, Suicide, and Trama. The TEP made recommendations for the next phase of measure development for the 6 behavioral health domains (listed above) with a focus on measures relevant for the Meaningful Use program. This phase did not involve full measure development but made recommendations for measures to be developed or retooled. Additionally, the TEP identified future measure development needs by evaluating available clinical research and provided private sector input regarding measure implementation feasibility.

Technical Expert Panel Results for Behavioral Health Domains

The TEP produced a set of reports related to each of the BH domains. These BH TEP Domain Reports represents their results of the second phase of the BH CQM Project.

  1. Alcohol Use [PDF - 751 KB]
  2. Autism [PDF - 662 KB]
  3. Depression [PDF - 1.05 MB]
  4. Drug Use [PDF - 915 KB]
  5. Suicide [PDF - 510 KB]
  6. Trauma [PDF - 450 KB]

Details about the measure development process can be found in the Measures Management System Blueprint.