The ways in which psychologists and other behavioral health care clinicians conduct the types of psychological assessment described in this chapter have undergone dramatic changes during the 1990s, and they will continue to change in this new millennium. Some of those involved in the delivery of psychological assessment services may wonder (with some fear and trepidation) where the health care revolution is leading the behavioral health care industry and, in particular, how their ability to practice will be affected in the twenty-first century. At the same time, others are eagerly awaiting the inevitable advances in technology and other resources that will come with the passage of time. What ultimately will occur is open to speculation. However, close observation of the practice of psychological assessment and the various industries that support it has led this author to arrive at a few predictions as to where the field of psychological assessment is headed and the implications they have for patients, clinicians, and provider organizations.
One way of discussing what the field is moving toward is to first talk about what it is moving away from. In the case of psychological assessment, two trends are becoming quite clear. First, as just noted, the use of (and reimbursement for) psychological assessment has gradually been curtailed. In particular, this has been the case with regard to indiscriminate administration of lengthy and expensive psychological test batteries. Payers began to demand evidence that the knowledge gained from the administration of these instruments in fact contributes to the delivery of cost-effective, efficient care to patients. This author sees no indications that this trend will stop.
Second, as the Piotrowski et al. (1998) findings suggest, the form of assessment commonly used is moving away from lengthy, multidimensional objective instruments (e.g., MMPI) or time-consuming projective techniques (e.g., Rorschach) that previously represented the standard in practice. The type of assessment authorized now usually involves the use of brief, inexpensive, problem-oriented instruments that have demonstrated validity for the purpose for which they will be used. This reflects modern behavioral health care's time-limited, problem-oriented approach to treatment. Today, the clinician can no longer afford to spend a great deal of time in assessment when the patient is only allowed a limited number of payer-authorized sessions. Thus, brief instruments will become more commonly employed for problem identification, progress monitoring, and outcomes assessment in the foreseeable future.
In addition to the move toward the use of brief, problem-oriented instruments, another trend in the selection of instrumentation is the increasing use of public domain tests, questionnaires, rating scales, and other measurement tools. In the past, these free-use instruments were not developed with the same rigor that is applied by commercial test publishers in the development of psychometrically sound instruments. Consequently, they commonly lacked the validity and reliability data that are necessary to judge their psychometric integrity.
Recently, however, there has been significant improvement in the quality and documentation of the public domain, free-use, and nominal cost tests that are available. Instruments such as the SF-36 Health Survey (SF-36; Ware, Snow, Kosinski, & Gandek, 1993) and the SF-12 Health Survey (SF-12; Ware, Kosinski, & Keller, 1995) health measures are good examples of such tools. These and instruments such as the Behavior and Symptom Identification Scale (BASIS-32; Eisen, Grob, & Klein, 1986) and the Outcome Questionnaire (OQ-45; Lambert, Lunnen, Umphress, Hansen, & Burlingame, 1994) have undergone psychometric scrutiny and have gained widespread acceptance. Although copyrighted, these instruments may be used for a nominal one-time or annual licensing fee; thus, they generally are treated much like public domain assessment tools. In the future, one can expect that other high quality, useful instruments will be made available for use at little or no cost.
As for the types of instrumentation that will be needed and developed, one can probably expect some changes.
Accompanying the increasing focus on outcomes assessment is a recognition by payers and patients that positive change in several areas of functioning is at least as important as change in level of symptom severity when evaluating treatment effectiveness. For example, employers are interested in the patient's ability to resume the functions of his or her job, whereas family members are probably concerned with the patient's ability to resume his or her role as spouse or parent. Increasingly, measurement of the patient's functioning in areas other than psychological or mental status has come to be included as part of behavioral health care outcomes systems. Probably the most visible indication of this is the incorporation of the SF-36 or SF-12 in various behavioral health care studies. One will likely see other public domain and commercially available, non-symptom-oriented instruments, especially those emphasizing social and occupational role functioning, in increasing numbers over the next several years.
Other types of instrumentation will also become prominent. These may well include measures of variables that support outcomes and other assessment initiatives undertaken by provider organizations. What one organization or provider believes is important, or what payers determine is important for reimbursement or other purposes, will dictate what is measured. Instrumentation may also include measures that will be useful in predicting outcomes for individuals seeking specific psychotherapeutic services from those organizations.
Looking back to the mid-1980s and early 1990s, the cutting-edge technology for psychological testing at that time included optical mark reader (OMR) scanning technologies. Also, there were those little black boxes that facilitated the per-use sale and security of test administration, scoring, and interpretations for test publishers while making computer-based testing convenient and available to practitioners. As has always been the case, someone has had the foresight to develop applications of several current technological advances that we use every day to the practice of psychological testing. Just as at one time the personal computer held the power of facilitating the testing and assessment process, the Internet, the fax, and interactive voice response, technologies are being developed to make the assessment process easier, quicker, and more cost effective.
The Internet has changed the way we do many things, so that the possibility of using it for the administration, scoring, and interpretation of psychological instruments should not be a surprise to anyone. The process here is straightforward. The clinician accesses the Web site on which the desired instrumentation resides. The desired test is selected for administration, and then the patient completes the test online. There may also be an option of having the patient complete a paper-and-pencil version of the instrument and then having administrative staff key the responses into the program. The data are scored and entered into the Web site's database, and a report is generated and transmitted back to the clinician through the Web. Turnaround time on receiving the report will be only a matter of minutes. The archived data can later be used for any of a number of purposes. The most obvious, of course, is to develop scheduled reporting of aggregated data on a regular basis. Data from repeated testing can be used for treatment monitoring and report card generation. These data can also be used for psychometric test development or other statistical purposes.
The advantages of an Internet-based assessment system are rather clear-cut. This system allows for online administration of tests that include branching logic for item selection. Any instruments available through a Web site can be easily updated and made available to users, which is not the case with disk-distributed software, for which updates and fixes are sometimes long in coming. The results of a test administration can be made available almost immediately. In addition, data from multiple sites can be aggregated and used for normative comparisons, test validation and risk adjustment purposes, generation of recovery curves, and any number of other statistically based activities that require large data sets.
There are only a couple of major disadvantages to an Internet-based system. The first and most obvious is the fact that it requires access to the Internet. Not all clinicians have Internet access. The second disadvantage has to do with the general Internet data security issue. With time, the access and security issues will likely become of less concern as the use of the Internet in the workplace becomes more of the standard and advances in Internet security software and procedures continue to take place.
The development of facsimile and faxback technology that has taken place over the past decade has opened an important application for psychological testing. It has dealt a huge blow to the optical scanning industry's low-volume customer base while not affecting sales to their high-volume scanning customers.
The process for implementing faxback technology is fairly simple. Paper-and-pencil answer sheets for those tests available through the faxback system are completed by the patient. The answer sheet for a given test contains numbers or other types of code that tell the scoring and reporting software which test is being submitted. When the answer sheet is completed, it is faxed in—usually through a toll-free number that the scoring service has provided—to the central scoring facility, where the data are entered into a database and then scored. A report is generated and faxed back to the clinician within about 5 minutes, depending on the number of phone lines that the vendor has made available and the volume of submissions at that particular time. At the scoring end of the process, the whole system remains paperless. Later, the stored data can be used in the same ways as those gathered by an Internet-based system.
Like Internet-based systems, faxback systems allow for immediate access to software updates and fixes. As is the case with the PC-based testing products that are offered through most test publishers, its paper-and-pencil administration format allows for more flexibility as to where and when a patient can be tested. In addition to the types of security issues that come with Internet-based testing, the biggest disadvantage of or problem with faxback testing centers around the identification and linking data. Separate answer sheets are required for each instrument that can be scored through the faxback system.
Another disadvantage is that of developing the ability to link data from multiple tests or multiple administrations of the same test to a single patient. At first glance, this may not seem to be a very challenging task. However, there are issues related to the sometimes conflicting needs of maintaining confidentiality while at the same time ensuring the accuracy of patient identifiers that link data over an episode or multiple episodes of care. Overcoming this challenge may be the key to the success of any faxback system. If a clinician cannot link data, then the data will be limited in its usefulness.
One of the more recent applications of new technology to the administration, scoring, and reporting of results of psychological tests can be found in the use of interactive voice response, or IVR, systems. Almost everyone is familiar with the IVR technology. When we place a phone call to order products, address billing problems, or find out what the balance is in our checking accounts, we are often asked to provide information to an automated system in order to facilitate the meeting of our requests. This is IVR, and its applicability to test administration, data processing, and data storage should be obvious. What may not be obvious is how the data can be accessed and used.
Interactive voice response technology is attractive from many standpoints. It requires no extra equipment beyond a touch-tone telephone for administration. It is available for use 24 hours a day, 7 days a week. One does not have to be concerned about the patient's reading ability, although oral comprehension levels need to be taken into account when determining which instruments are appropriate for administration via IVR or any audio administration format. As with fax- and Internet-based assessment, the system is such that branching logic can be used in the administration of the instrument. Updates and fixes are easily implemented systemwide. Also, the ability to store data allows for comparison of results from previous testings, aggregation of data for statistical analyses, and all the other data analytic capabilities available through fax- and Internet-based assessment. As for the down side of IVR assessment, probably the biggest issue is that in many instances the patient must be the one to initiate the testing. Control of the testing is turned over to a party that may or may not be amenable to assessment. With less cooperative patients, this may mean costly follow-up efforts to encourage full participation in the process.
Overall, the developments in instrumentation and technology that have taken place over the past several years suggest two major trends. First, there will always be a need for the commercially published, multidimensional assessment instruments in which most psychologists received training. These instruments can efficiently provide the type of information that is critical in forensic, employment, or other evaluations that generally do not involve ongoing treatment-related decision-making. However, use of these types of instruments will become the exception rather than the rule in day-to-day, in-the-trenches clinical practice. Instead, brief, valid, problem-oriented instruments whose development and availability were made possible by public or other grant money will gain prominence in the psychologist's armamentarium of assessment tools. As for the second trend, it appears that the Internet will eventually become the primary medium for automated test administration, scoring, and reporting. Access to the Internet will soon become universal, expanding the possibilities for in-office and off-site assessment and making test administration simple, convenient, and cost effective for patients and psychologists.
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