Measurement-based care: how the Outcomes page works
See where the numbers on the Outcomes page come from, what each tile means, and how to read the trend, stratification, and CMS coverage views.
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- Updated
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- Tags
- outcomesmbcphq-9gad-7mips
Every screener, one dashboard
PHQ-9, GAD-7, AUDIT - the scores your patients already submit, rolled into one live view of your panel
Measurement-based care (MBC) means asking patients to fill out validated screeners — PHQ-9, GAD-7, AUDIT, WHODAS — on a regular cadence and using the scores to steer treatment. The problem MBC solves is well known: clinicians are excellent at noticing acute change in front of them, and worse at noticing slow drift across a 200-patient panel. Without numbers you cannot see who is plateauing on a med, which modality is working, or whether you would pass a CMS quality measure. The Outcomes page turns the responses your patients already submit into a single live dashboard you can answer those questions from in under a minute.
Where the data comes from
Every screener your clinic has enabled (Establishment → Surveys) gets sent to assigned patients on its cadence. When a patient completes a screener — in the portal, by SMS link, or in the room with a clinician — the response and its computed score land in the patient chart and roll up into the establishment-wide Outcomes page automatically. There is no separate "publish" step. If a screener is sent and a patient answers, you see it on Outcomes the next time you load the page.
Picking a window
The window selector at the top of the page controls every number below it. 30d is your week-over-week pulse — useful when you have just changed protocols. 90d (the default) is the clinical sweet spot: long enough that random noise washes out, short enough that a med change two months ago still shows up. 180d and 365d are for board reports and payer attestations. The "patients enrolled in MBC" pill on the right is a count of distinct patients with at least one active screener assignment, regardless of whether they have responded yet.
Reading a screener tile
9-item Patient Health Questionnaire. Lower is better.
9.4/ 27
Mean score, last 90 days
Enrolled
184
Response rate
82%
Reliable improvement
38%
Each enabled screener gets its own tile. The big number is the mean score across every response in the window — for PHQ-9 lower is better, for WHODAS lower is better, etc. The arrow next to it compares the current window mean to the prior window of the same length, so a 90d view compares the last 90 days against the 90 days before that. The sparkline shows weekly buckets of the mean across the window so you can spot trend shape, not just direction. Enrolled is how many patients have an active assignment for that screener; response rate is the percent of those enrolled who completed at least once in the window; reliable improvement is the percent of patients (with both a current AND prior response) whose score dropped by at least the screener-specific reliable-change threshold (≈20% of score range, floor of 3 points).
Stratification — what is actually moving the needle
Compare modalities to spot which interventions are moving outcomes most
Virtual visit
n = 86
In-person
n = 112
No active treatment
n = 14
A mean by itself does not tell you *why* outcomes are moving. The PHQ-9 stratification chart splits the same panel by visit modality (telehealth vs in-person) using each patient's predominant visit type in the window. A bar to the left of center means that segment is improving (negative delta = lower depression score). A bar to the right means the segment is getting worse. Tiny n? Treat the bar as directional, not statistical. We surface modality because that is the dimension every practice can act on this quarter; richer stratifications (med + therapy vs med-only, by provider, by diagnosis) are on the roadmap.
CMS / MIPS quality coverage
CMS2v12 coverage
312 of 348 eligible patients (89.7%) have a documented PHQ-9 in the last 12 months - meeting the MIPS quality measure benchmark of 75%.
CMS2v12 ("Depression Screening: PHQ-9") is one of the highest-leverage MIPS quality measures for behavioral-health-adjacent practices. The coverage card answers a single question: of the patients who actually came in over the last 12 months, what fraction has a documented PHQ-9 in that same window? The MIPS benchmark is 75%. We render a Meeting badge in green when you are at or above the benchmark and a neutral badge when you are below it, so you can see at a glance whether you would pass the measure if your reporting period closed today.
Who can see this page
Outcomes is gated by the managesurveys role. By default that means providers, clinical staff, and practice managers (anyone who can already assign a screener). Front-desk and billing-only roles do not see the page in the sidebar. If you are an admin and want to grant access to a non-default role, edit the role under Establishment → Roles and check managesurveys. Outcomes is also a paid feature — if your plan does not include it, the page renders as a blurred preview behind a See plans overlay so you can decide whether to upgrade without leaving the app.
Troubleshooting common views
Empty state ("No screeners enrolled yet") — your establishment has no enabled practice_surveys. Go to Establishment → Surveys and enable PHQ-9 (or whichever screener fits your specialty) to start collecting data. Tile shows enrolled but 0% response rate — assignments exist but no patient has completed the screener in the current window. Send a reminder from the patient chart, or shorten the window to confirm whether responses just happened to fall outside it. Stratification empty — you do not yet have paired responses (one in the prior window, one in the current window) within each modality. Wait one more cadence cycle.
Frequently asked questions
Is this view real-time?
How is "reliable improvement" calculated?
Why are scores rendered as `mean / 10` in the headline?
Will this export?
outcomes(window_days:) query returns the same shape.Why telehealth-vs-in-person and not med-vs-therapy?
med + therapy, med only, therapy only) require a structured care-plan model that is on the roadmap; we will not stratify on a dimension you have not explicitly recorded, because that produces misleading lines.