Assessments of a health-related matter of interest, importance, or worry to a patient, patient’s family, or patient’s healthcare provider that could identify a need, problem, or condition.

Data Element
Mental Health Status
Description

Assessment of or screening for the presence of a mental or behavioral health condition.
Submitted By: Michael Schoenbaum / National Institute of Mental Health
Data Element Information
Rationale for Separate Consideration Mental Health Status must be a separate and distinct data element in USCDI. We strongly suggest that USCDI divide the existing Mental/Cognitive Status element into two separate elements, Mental Health Status and Cognitive Status. These are two completely separate clinical concepts. Though it makes sense for both elements to remain under the larger Health Status Assessment class, we believe that they should be seperated into their component parts because they are clinically separate entities which are evaluated using entirely different assements . Keeping these clinically disparate entities within the same data element could perpetuate confusion, especially among those outside of the neuropsychiatric field. Cognitive status is an element that includes orientation, atteention, memory, judgement and reasoning. It is typically evaluated using assessments such as the MOCA, SLUMS, or MMSE. Mental Health status, on the other hand, includes diagnoses like depression, anxiety, ADHD and suicidal ideation, and is evaluated using assessesments like PHQ-9, GAD-7, Vanderbilt Assessment Scale, and the Columbia Suicide Severity Rating Scale (C-SSRS).
Use Case Description(s)
Use Case Description According to the Center for Disease Control and Prevention (CDC), more than 50% of people in the Unites States will be diagnosed with a mental illness or disorder at some point in their lifetime and 1 in 5 Americans will experience a mental illness in a given year. There are over 57 million visits to physician offices with mental disorders as the primary diagnosis per year in the United States and over 8.7 million visits in which attention deficit hyperactivity disorder is the primary diagnosis. In addition, the U.S. Preventive Services Task Force (USPSTF) has been recommending screening for depression in the entirety of the general adult population, including pregnant and postpartum women since 2016 and screening for major depressive disorder (MDD) in adolescents aged 12 to 18 years, as well as screening for anxiety in children and adolescents aged 8 to 18 years since 2022. Finally, due to large-scale deleterious impacts on physical health, mental health, and functional status, depression has been a longstanding priority diagnosis for NCQA and HEDIS. This is especially because patient-reported outcome measures, which are required for depression measurement, have historically been challenging to collect through conventional HEDIS workflows. Consequently, the need to develop outcome measures that assess the quality of depression care was a primary impetus for the HEDIS Electronic Clinical Data Systems (ECDS) approach. HEDIS now contains five depression care measures, one of which is focused specifically on the PHQ-9 and measures the percentage of members 12 years of age and older with a diagnosis of depression who had an outpatient encounter with a PHQ-9 score present in their record in the same assessment period as the encounter.
https://www.cdc.gov/mentalhealth/index.htm
https://www.ncqa.org/hedis/the-future-of-hedis/hedis-depression-measures-specified-for-electronic-clinical-data/
Estimate the breadth of applicability of the use case(s) for this data element Stakeholders who would capture, access, use, or exchange Mental Health Status data include: hospitals, emergency departments, primary care providers, behavioral health providers, pediatricians, obstetricians other clinicians, FQHCs, long term care facilities and patients. The U.S. Preventive Services Task Force (USPSTF) has recommended screening for depression in the entireity of the general adult population, including pregnant and postpartum women since 2016. They have recommended screening for major depressive disorder (MDD) in adolescents aged 12 to 18 years, as well as screening for anxiety in children and adolescents aged 8 to 18 years since 2022 and are currently finalizing their recommendation for screening for anxiety in adults, including pregnant and postpartum persons. Further, the Joint Commission has several health care accreditation standards that require providers and facilities to use valid standard measures of mental health status, including measures for depression, anxiety and other specific behavioral health conditions, and for suicide risk: Outcome Measures Standard CTS 03.01.09, for behavioral health providers; and Suicide Prevention National Patient Safety Goal 15.01.01, for hospitals (including hospital emergency departments) and behavioral health facilities and providers.
Link to use case project page https://www.jointcommission.org/what-we-offer/accreditation/health-care-settings/behavioral-health-care/outcome-measures-standard/ ; https://www.jointcommission.org/resources/patient-safety-topics/suicide-prevention/
Supporting Attachments USCDI v4 comment from NIMH 17Apr23.pdf
Healthcare Aims
  • Improving patient experience of care (quality and/or satisfaction)
  • Improving the health of populations
  • Reducing the cost of care
  • Improving provider experience of care
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s) Various specific mental health status measures exist in LOINC, including the PHQ-9 for depression, the GAD-7 for anxiety, and the C-SSRS for suicide risk.
Additional Specifications N/A
Current Use This data element has been used at scale between multiple different production environments to support the majority of anticipated stakeholders
Supporting Artifacts • USPSTF recommendation on depression screening: https://www.uspreventiveservicestaskforce.org/uspstf/draft-recommendation/screening-depression-suicide-risk-adults (adults), https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-depression-suicide-risk-children-adolescents (adolescents)
• USPSTF recommendation on anxiety screening: https://uspreventiveservicestaskforce.org/uspstf/draft-recommendation/anxiety-adults-screening (adults), https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-anxiety-children-adolescents(adolescents)
• NCQA HEDIS depression screening: https://www.ncqa.org/hedis/measures/depression-screening-and-follow-up-for-adolescents-and-adults/ (PHQ-2/PHQ-9 are included in the measure definition)
• NCQA HEDIS depression symptom monitoring: https://www.ncqa.org/hedis/measures/utilization-of-the-phq-9-to-monitor-depression-symptoms-for-adolescents-and-adults/ (PHQ-9 is required by the measure)
• NCQA HEDIS depression remission/response: https://www.ncqa.org/hedis/measures/depression-remission-or-response-for-adolescents-and-adults/ (PHQ-9 is required by the measure)
• CMS MIPS 2023 Quality Measures List: https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2217/2023%20MIPS%20Quality%20Measures%20List.xlsx (includes measures that require PHQ-9)
• CMS MIPS 2023 Qualified Clinical Data Registry (QCDR) Measure Specifications: https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2174/2023_QCDR_Measure_Specifications.xlsx (includes measure that requires GAD-7)
• Joint Commission Outcome Measures Standard (CTS 03.01.09): https://www.jointcommission.org/what-we-offer/accreditation/health-care-settings/behavioral-health-care/outcome-measures-standard/; associated Behavioral Healthcare Instruments Listing: https://manual.jointcommission.org/BHCInstruments/ (includes PHQ and GAD-7)
• Core Quality Measures Collaborative (CQMC): https://www.qualityforum.org/cqmc/; CQMC Core Measure Sets: https://www.qualityforum.org/CQMC_Core_Sets.aspx; Behavioral Health Measures: https://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=94322 (includes depression screening, which includes PHQ; and depression remission and response, which require PHQ-9)
• Service requirements for General Behavioral Health Integration (CPT 99484): per Medicare Learning Network (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/BehavioralHealthIntegration.pdf), 99484 requires:
• Initial assessment, including administering applicable validated rating scales
• Systematic assessment and monitoring, using applicable validated clinical rating scales
• Service requirements for Psychiatric Collaborative Care Model (CPT 99492, 99493, 99494): per Medicare Learning Network (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/BehavioralHealthIntegration.pdf), these require:
• Behavioral Health Care Manager (needed for CoCM) gives assessment and care management services, including: Administering validated rating scales; revisions for patients not progressing or whose status changes
• Joint Commission National Patient Safety Goal 15.01.01: https://www.jointcommission.org/standards/r3-report/r3-report-issue-18-national-patient-safety-goal-for-suicide-prevention/ (includes C-SSRS)
Extent of exchange 5 or more. This data element has been tested at scale between multiple different production environments to support the majority of anticipated stakeholders.
Supporting Artifacts • USPSTF recommendation on depression screening: https://www.uspreventiveservicestaskforce.org/uspstf/draft-recommendation/screening-depression-suicide-risk-adults (adults), https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-depression-suicide-risk-children-adolescents (adolescents)
• USPSTF recommendation on anxiety screening: https://uspreventiveservicestaskforce.org/uspstf/draft-recommendation/anxiety-adults-screening (adults), https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-anxiety-children-adolescents(adolescents)
• NCQA HEDIS depression screening: https://www.ncqa.org/hedis/measures/depression-screening-and-follow-up-for-adolescents-and-adults/ (PHQ-2/PHQ-9 are included in the measure definition)
• NCQA HEDIS depression symptom monitoring: https://www.ncqa.org/hedis/measures/utilization-of-the-phq-9-to-monitor-depression-symptoms-for-adolescents-and-adults/ (PHQ-9 is required by the measure)
• NCQA HEDIS depression remission/response: https://www.ncqa.org/hedis/measures/depression-remission-or-response-for-adolescents-and-adults/ (PHQ-9 is required by the measure)
• CMS MIPS 2023 Quality Measures List: https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2217/2023%20MIPS%20Quality%20Measures%20List.xlsx (includes measures that require PHQ-9)
• CMS MIPS 2023 Qualified Clinical Data Registry (QCDR) Measure Specifications: https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2174/2023_QCDR_Measure_Specifications.xlsx (includes measure that requires GAD-7)
• Joint Commission Outcome Measures Standard (CTS 03.01.09): https://www.jointcommission.org/what-we-offer/accreditation/health-care-settings/behavioral-health-care/outcome-measures-standard/; associated Behavioral Healthcare Instruments Listing: https://manual.jointcommission.org/BHCInstruments/ (includes PHQ and GAD-7)
• Core Quality Measures Collaborative (CQMC): https://www.qualityforum.org/cqmc/; CQMC Core Measure Sets: https://www.qualityforum.org/CQMC_Core_Sets.aspx; Behavioral Health Measures: https://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=94322 (includes depression screening, which includes PHQ; and depression remission and response, which require PHQ-9)
• Service requirements for General Behavioral Health Integration (CPT 99484): per Medicare Learning Network (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/BehavioralHealthIntegration.pdf), 99484 requires: Initial assessment, including administering applicable validated rating scales; Systematic assessment and monitoring, using applicable validated clinical rating scales
• Service requirements for Psychiatric Collaborative Care Model (CPT 99492, 99493, 99494): per Medicare Learning Network (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/BehavioralHealthIntegration.pdf), these require: Behavioral Health Care Manager (needed for CoCM) gives assessment and care management services, including: Administering validated rating scales; revisions for patients not progressing or whose status changes
• Joint Commission National Patient Safety Goal 15.01.01: https://www.jointcommission.org/standards/r3-report/r3-report-issue-18-national-patient-safety-goal-for-suicide-prevention/ (includes C-SSRS)
Potential Challenges
Restrictions on Standardization (e.g. proprietary code) None known, in fact many of the assessments which already have LOINC codes, including the PHQ-2, PHQ-9, and GAD-7 are publically available and be administered by a variety of staff.
Restrictions on Use (e.g. licensing, user fees) None known, in fact many of the assessments which already have LOINC codes, including the PHQ-2, PHQ-9, and GAD-7 are publically available and be administered by a variety of staff. To our understanding, the C-SSRS is open source or royalty-free.
Privacy and Security Concerns Having mental health and substance use conditions is stigmatized, often beyond many types of physical health conditions, but HIPAA and other existing protections of PHI are adequate for this use case.
Estimate of Overall Burden Minimal -- for more information, see Screening For Behavioral Health In Primary Care Settings: A Review Of The Literature

The tools included in this comment are designed to be brief and should take fewer than 8 minutes to administer/self-report. These tools are free (with the exception of the BDI Fast Screen) and may be administered via patient portal, in office tablet/kiosk or paper and pencil. Many are already available within the EHR and/or patient portal and scores are calculated automatically within the production environment. The completion of these tools can be done prior to, while waiting for, or during a primary care (or specialty) appointment and will not interrupt the normal clinician workflow.
ONC Evaluation Details
Each submitted Data Element has been evaluated based on the following criteria. The overall Level classification is a composite of the maturity based on these individual criteria. This information can be used to identify areas that require additional work to raise the overall classification level and consideration for inclusion in future versions of USCDI
Criterion #1
Maturity - Current Standards		 Level 2 - Data element is represented by a terminology standard or SDO-balloted technical specification or implementation guide.
Criterion #2
Maturity - Current Use 		Level 2 - Data element is captured, stored, or accessed in multiple production EHRs or other HIT modules from more than one developer.
Criterion #3
Maturity - Current Exchange		 Level 2 - Data element is electronically exchanged between more than two production EHRs or other HIT modules of different developers using available interoperability standards.
Criterion #4
Use Case(s) - Breadth of Applicability		 Level 0 - Use cases apply to a limited number of care settings or specialties, or data element represents a specialization of other, more general data elements.
Evaluation Comment This submission represents a data element that is a subset of another data element Mental/Cognitive Status (https://www.healthit.gov/isa/taxonomy/term/1616/draft-uscdi-v4) with was first added to USCDI in version 3.

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