Health Information Technology (HIT) has transformed physical healthcare in the United States over the past decade. Over 90% of hospitals now use an electronic medical record. And, patients can access and refill their medications through apps. But take a look at behavioral medicine and you’ll find a patchwork of services, disorganized clinics, restrictions on information disclosure, and a high number of psychiatrists who still use paper charts.
Why isn’t mental health technology up to par with its medical health counterparts? These three key factors contribute to the lag:
- 50 different state legal rules
- poor reimbursement rates and low funding
- a lack of technical expertise
The Open Minds Technology and Informatics Institute
At the most recent Open Minds Technology and Informatics Institute (#OMTechnology), speakers from government and industry discussed the problems facing behavioral health technology. Entrepreneurs and innovators have created pilot programs with both Centers for Medicare and Medicaid Services and individual innovation groups. Combined with the recent 2016 United States election results, and you have a recipe for high nervousness and anxiety.
As the newly appointed Chief Medical Officer of United States Center for Medicare and Medicaid Services (CMS), Andrey Ostrovsky, MD, put it,
“If you think you have it bad, it can always get worse. But there is opportunity in uncertainty. The only thing that’s certain is uncertainty.”
The opportunity includes new interventional psychiatric and neurosurgical techniques, cost containment pressure from capitated reimbursement rates, and a high demand for the sharing of data.
So, what should you—as a behavioral healthcare administrator, psychiatrist, psychologist, social worker, innovator, or entrepreneur—be aware of when looking at mental health technology? I have divided my observations into four main themes:
Theme #1: There’s not enough money in mental health technology
There’s not enough funding allocated towards behavioral health technology. Funding is a major issue preventing behavioral health providers from adopting technology. In other medical specialties, the United States federal government provided tens of billions of dollars towards the purchase of electronic systems but excluded psychologists, social workers, and long-term care facilities. In fact, 36% of mental health organizations in a 2016 Open Minds survey don’t even use electronic scheduling. Most of the technology in behavioral health is geared towards finance. There is frequently an underinvestment in help and support staff, infrastructure, and often forgetting to fund software updates. In fact, many behavioral health groups rely on one person to handle all the technology needs, which equates to one single point of failure.
There’s not enough technology currently in use. While a majority (74%) use an electronic health record—beyond the classic paper charts made to work on computers—only 29% of the organizations with the ability to share actually share data. Thirty-one percent of organizations still don’t even have the ability to share data. This means that less than 15% of all behavioral health organizations are able to share data in order to coordinate care. This is like being on Facebook but only being able to post articles to your own wall—and not being able to share links to funny sites, read your friend’s posts, or even add friends!
Bruce Bird of Vinfen Corporation believes this will change in the next two years:
“The demand for data to go into electronic health records is there.”
There is opportunity here to fill the vacuum.
Funding mechanisms need to improve. Payers will develop sustaining funds, but there’s no fee-for-service for these technologies yet. One thing that speakers at the conference agreed on: Value-based care and contracts have bipartisan support because value-based care encourages people to do more with less. CMS’ CMO, Andrey Ostrovsky, also stresses that the promise of access, quality, and cost containment with managed care is likely to continue seeing gains at the expense of fee-for-service. Technology is part of that.
Theme 2: Many other factors need to change
Research methods will change. Randomized controlled trials were built on agricultural research, says Bird. New “agile science” methods from the information technology world will help healthcare systems choose technologies.
“ The typical randomized-controlled trials are too long, as technology changes within a year. We need to curate technology, get new statistical methods, and new research methods.”
Legal barriers stymie start-ups. Much of mental health is funded locally, not federally, and is counted as a “social service” versus the robust funding given to other medical specialties. Funding pathways are complex. States fund mental health services and each state has its own rules. Mental health services that are funded are, in turn, administered by counties. This, of course, complicates data collection. Help via technology may be on the horizon: Andrey Ostrovsky discussed how the Transformed Medicaid Statistical Information System (T-MSIS) provides more analytical insights for the enrolled 19 states.
Education of patients and doctors will have to change. Healthcare is moving from a clinic-centric model to patient-centric model that includes the use of the Internet, self-education, and even self-help. Patients are already encountering four types of online health resources:
- informational and educational
- home testing, screening, and measurement
- social support with other peers facing similar issues
- interventions in which computers provide the therapy
One such example is Beating The Blues, a cognitive behavioral technology in the United Kingdom and New Zealand that gained popularity because of those countries’ national capitated health services.
While all of this is good news for patients, clinicians have not necessarily embraced patient self-help via the web. Dennis Morrison, Ph.D, Chief Clinical Officer of Netsmart (@DrDennyM) points out that,
“Clinicians are not trained to send people to a website!”
Your operational workflow needs to change. Pat Deegan (@PatDeegan) of Commonground Software works with Medicaid clinics. She moves clinics away from “useless waiting rooms” with long waits into places where patients can walk in and immediately engage with peers who, themselves, are experiencing the same illness. The peer specialist walks patients through their visit with the aid of a tablet that they use to conduct screening questionnaires for use in the clinical appointment. They can also use it to provide patient education. But dropping an app on a tablet is not be enough.
You need to get buy-in from staff. Again, dropping an app or technology in isn’t enough. According to Davis Park of the Front Porch Center for Innovation and Wellbeing,
“Technology is 10%. Support, outreach, recruitment, buy-in, and organizational culture is 90%.”
According to Minky Kernacs, Enterprise Architect at the Philadelphia Department of Behavioral Health & Intellectual disAbility Services (@DBHIDS, @MinkySKernacs), “naysayers” will resist the technology, especially persons who fear the loss of their jobs. Engaging them is important as naysayers often point out a technology’s largest deficiencies. They have the potential to become rigorous beta testers and not only make the product better, but also eventually become its biggest supporters.
The culture is already shifting in favor of technology notes Socorro Gertmenian, Ph.D., Director of Quality Management at Los Angeles Child Guidance Clinic:
“New graduates [of mental health programs] are used to electronic systems. They ask us, ‘Why aren’t you documenting on tablets?’”
To incorporate technology into organizations is an art according to Monica Oss (@MonicaOss) of OpenMinds. She stresses the use of implementation sciences saying,
“Use the well-researched processes in other industries to implement these technologies and organizational changes.”
Theme #3: Technology is available to help behavioral healthcare
Assessments are being pushed onto lower-cost devices. Sixty-three million persons annually go through a psychiatric interview in the United States—often taking an hour with a physician or trained professional. Craig Rhinehart Director, IBM Watson Health Innovation and Market Development, IBM Watson Health (@CraigRhinehart) asked in a keynote speech,
“This is a high-cost low-throughput model, Why not have assessments on smartphones?”
Well, cognitive assessments by computerized speech and text analysis have been done in prediction of prodromal psychosis and assessment of Parkinson’s disease, mild cognitive impairment, Alzheimer’s dementia, Huntington’s dementia, and even depression and autism spectrum disorders. In fact, these don’t have to be one-time psychiatric assessments. Digitized questionnaires can be used to perform continuous, ongoing evaluations. Morrison notes that,
“The future is less expensive professionals doing more sophisticated things in less expensive settings.”
Population health systems and cognitive computing can help predict the highest risk patients—to get them the care they need. IBM Watson (@IBMWatson) and Netsmart Technologies (@netsmarttech) are working on aggregating data for population health. And, cognitive computing, overall, is moving beyond research. IBM Watson has paired up with Memorial Sloan Kettering, the VA Health System, Mayo Clinic, and many other partners in pilot projects to help with clinical assessments.
Computers can augment clinical capabilities and let them reach new audiences. Technologies can change the way clinicians make decisions. For example, desktop genetic sequencers can run a genome for $1,000 per pass. This is important in mental health, as genes affect patients’ responses to medications. And, telepsychiatry and tele-mental health—where patients can talk to clinicians over video conferencing webcams and fast connections—are here to stay. According to Chris Slocum, LCSW MBA, Vice President of Clinical Operations at Aetna Behavioral Health,
“We’ve pushed [telehealth] for increased access, since there are so few psychiatrists these days. Telehealth helps us track outcomes and access emergency departments and rural health. We’ve seen high engagement in telehealth.”
Thoroughly vet companies and products before buying. Like any investment, you want the technology company to be there with you in the long run, says Bruce Bird of Vinfen Corporation, an agency contractor in Massachusetts that runs assertive community treatment teams and mental health services. Thoroughly vet them with selection criteria, he says. Vinfen, for instance, looks at a whopping 72 different criteria ranging from data collection types to data reporting and the ever-elusive lack of linkage to the electronic health record. Do not choose the hottest-sounding vendor as they may not exist in a year.
This includes smartphone apps. It’s okay to not be “bleeding edge.” No single mobile health app has been effective so far, says Bird. Many persons stop using apps after 1 to 2 weeks. You should look for sound statistics & methods in any app’s usage statistics, including data based on outcomes for “all starters”—that is all patients who start using an intervention even though they may or may not finish it.
Mental health technology companies can be in flux, fail, and fly away. What if the company fails to deliver what you paid for? Insist on penalties written into contracts so you are protected if the technology is not delivered. Have a contingency plan when your tech vendor disappears or fails to follow through on their commitment. Vinfen Corporation tested technologies from large vendor Bosch, putting the Heath Buddy home health device through pilot studies. However, Bosch manufacturer pulled out of the United States market entirely, leaving Vinfen to find a completely new vendor.
Theme 4: In the future, more advanced interventions could help with mental illness
Neurosurgical technologies could have an impact on mental illness. For example, a DARPA-funded project called Stentrode involves placing a stent through the blood vessels in the neck in order to detect neural activity. Brain implants can listen to neurons and stimulate neurons. These implants can change a fly’s travel patterns—as demonstrated in a project called HiMEM, which stands for Hybrid Insect Micro-ElecroMechanical Systems. And, for paraplegia, spinal cord damage paralyzing the arms and legs, new brain implants can give them the ability to control artificial hands.
Don’t underestimate the cuddly. Davis Park of Front Porch Center for Innovation and Wellbeing tested the robotic dog, Biscuit, and PARO, the animatronic seal, with residents of nursing homes and long-term care facilities. These smart toys, manufactured to withstand physical violence and are made with antibacterial fur, are used to decrease agitation, anxiety, social isolation, pacing, and wandering behaviors in those with dementia and cognitive issues. In fact, Park says they found that these toys helped increase socialization, smiling, and other positive behaviors, which, of course, can be a challenge in nursing homes and long-term care facilities.
Collaborative Care models will save a lot. Collaborative care marries together primary care and physical health management with behavioral health assessment and treatments. Some models include embedding psychiatrists into primary care clinics. Other clinics do the reverse, embedding internists or family medicine specialists into mental health clinics. According to Ostrovsky, there is a $6.50 savings for every $1.00 invested in this type of practice.
The bottom line
Behavioral health providers and agencies have faced a lack of resources when compared to other medical specialties. The good news: Many recognize that new technologies can help improve the quality of healthcare, save money, and even boost access to behavioral health experts. When implemented correctly, behavioral health technologies can prove to be a solid long-term investment and improve the well-being of Americans.