Challenges and new opportunities with behavioral health data
Addiction treatment facilities as tricky setting to improve patient outcomes
Describing the patient experience, Dr. Steve Miller, kidney transplant specialist and Chief Medical Officer at Cigna, said during a recent panel: “We’ve created a really horrible experience for patients from start to finish. You go to see me as a doctor, and I’m sitting there with my eyes down making love to a keyboard. I barely have time to acknowledge you, and when I finally get off the stool and come to examine you, you get a brief once-over, and then it’s time to go.”
It seems counterintuitive that “data” is at the heart of improving the human, “patient” experience. And yet, that is precisely the theme that has ramped up among health care thought leaders, across the continuum of care — including, this was the main variation on last year’s theme at HIMSS again this year.
Pinning any sort of solutions around data poses a real problem when we look at how to improve the patient journey in behavioral health, however. Here are just some of the challenges explaining why, along with some of the most recently discussed opportunities.
Mental has everything to do with physical, and vice versa
As more population health management (PHM) efforts are being made, to treat not just an illness, but the entire patient, we now know that mental health has a strong correlation with physical health. For example, people who suffer from depression are at increased risk for cardiovascular disease, diabetes, stroke, Alzheimer’s disease, and even osteoporosis. And those diet pill commercials are medically “correct” when they talk about depression or stress causing increased levels of cortisol, increased inflammation, and related heart rate and blood pressure fluctuations.
Conversely, patients with chronic medical conditions may be at increased risk of depression. Illness-related stress and anxiety, such as how patients adjust to new physical realities after a heart attack, or after completing cancer treatment, are easy examples to better understand the connection from this direction as well.
It has not known whether the strongest correlations lie within the domain of social determinants of health — these persons having less access to medical care in some way — or if there is more of a physiological connection between depression and these various chronic conditions. Parkinson’s disease and strokes are examples here, because they can cause brain damage with the areas that are responsible for emotional well-being.
Behavioral health plagued with more paper, inefficient workflows
Behavioral health treatment is not only complex, but “still a time-consuming process requiring individual diagnosis, (and) largely driven by paper and trial and error guesswork,” according to Health Data Management.
When the transition began from paper to electronic health records (EHRs) as part of the 2009 American Recovery and Reinvestment Act (ARRA)’s HITECH Act, the focus was on all specialties that were not behavioral in nature. (Legislation was soon after introduced to “extend the incentives for meaningful use” of EHRs to behavioral health and substance abuse providers, the co-sponsor of which was also a psychologist, who explained that untreated depression could double the costs associated with caring for chronic disease patients.)
Consider how behavioral health is assessed, and therein lies another challenge. Unlike an x-ray that clearly communicates data that aids in a diagnosis and treatment, behavioral health assessments are more subjective per provider — what can be inferred about a patient’s mental state from their movements, emotional moods, social interactions, tone of voice, word choices and facial expressions. The frequency and methodologies of these assessments varies per behavioral treatment center, not to mention the manual processes and documentation preferences involved.
Not that there isn’t a clinical care component involved — a substance abuse addiction patient must often undergo both a physical and mental exam before they are admitted to a treatment center — but you can safely guess that, again, there are some manual processes and paper documentation involved, and that the various IT systems at play are likely not talking with one another. Or best-case scenario, behavioral health records may be attached to a patient’s EHR as a PDF “read-only” file.
“A blob of data, as obtained from free form text fields, is not ‘discreet,’ neatly organized into rows and columns, so it cannot be reported on. So this, being used to store data in Behavioral EHRs, is not ideal, but we can still use what the systems have the capability to do today, and add value to the provider and patient by getting even this high level data to integrate between systems,” said John Milano, Bridge Connector Director of Solution Engineering. “Minimum data standards have gotten us to where we are with the evolution of data and EHRs, but unfortunately behavioral health is still a bit behind the times due to legislation not driving EHR use like we saw during meaningful use for acute care systems.”
Similar to the complicated workflows associated with post-acute “transitions of care,” behavioral health can feel even more disconnected because of the factors that must be addressed beyond the clinical aspects, the chemical and physiological aspects of addiction in this case. Many of these patients did not arrive at treatment centers of their own volition — some were ordered there by a judge, others by friends or family. And there can be resulting social concerns, financial and legal ramifications to manage long after patients are discharged from these facilities, such as divorce or child custody issues, bankruptcy or even jail time. Managing these sorts of aspects becomes the real work, and they can often be strong contributing factors with a relapse. The unfortunate reality is that a high percentage of addiction treatment patients relapse, making alumni marketing an additional series of workflows these facilities have to think about.
“Where we can streamline processes is with admissions intake, sharing patient data between systems, and as a secondary level of improvement, you can more readily track level of care, because we can update external systems. Where is the patient currently? Did they switch levels of care? That’s an important data point that we help drill down with integrations we are currently providing in behavioral care,” said Milano. “Not to mention, we have also automated patient information at discharge back into a CRM to better facilitate alumni marketing efforts.”
Privacy concerns and stigma are real
Most mental health facilities were called “asylums” as recently as the mid-1800s. And while we have come a long way since then, we must acknowledge that stigma still exists around mental health diagnoses and treatment. The National Alliance on Mental Illness estimates that one in five Americans experience mental illness in a given year. And yet, nearly 60 percent of these persons don’t receive any related services to treat their various conditions. People don’t want to be seen as “crazy” or “unfit,” and research supports that ignoring mental illness for such stigma reasons can lead to further isolation, worsening depression and increasing mortality rates, particularly among older men and women.
There is a federal statute in particular also standing in the way, 42 CFR Part 2, circa 2010. Framed around privacy concerns, it was designed to protect substance use disorder patients from stigma and fear of legal prosecution, by keeping that information separate from their clinical records. But the negative consequences of this policy have been heightened in the years since — physicians don’t have a comprehensive view of these patients. What behavioral and physical health connections are getting missed as a result? And how do you improve patient quality of care, if the whole individual is not being treated?
Addiction, as it turns out, is complicated to treat
While behavioral health refers to the broadest category being discussed here, it should be noted that there is great overlap in terms and cases with around 45 million Americans experiencing mental illness, and around 20 million experiencing a substance use disorder. An alarming 8.2 million Americans are affected by both. And substance abuse or addiction treatment care plans are as varied as there are individuals.
In the U.S., there are more than 14,000 specialized drug treatment facilities, which could range from inpatient, outpatient, and residential settings. The types of intervention services similarly span a wide swath to treat the complexity of addiction — medication, physical health monitoring, behavioral counseling, therapy, case management — which can be administered by everyone from medical physicians, nurses or social workers, to mental health counselors, psychiatrists and psychologists.
How does the U.S. addiction treatment landscape compare to other countries? We’re not sure in terms of the sheer number of treatment facilities, but a 2007 study of 17 countries put the U.S. first in illicit drug use, including cocaine. And this data doesn’t even really take into account the opioid epidemic. While actively progressing since the time of this earlier study, opioid use hit full-blown crisis proportions in 2017, when some states experienced over 50 percent higher opioid overdose deaths, from 2016 to 2017 alone. This, in addition to increased suicide rates in recent years.
Houston, we have a problem — a major and resulting chasm from the lack of behavioral health data we can utilize to improve patient outcomes.
OPIOID CRISIS NECESSITATES NEW BIPARTISAN ACTION
When the CDC calculates the total economic burden of “prescription opioid misuse” at over $78 billion a year (in health care costs, lost productivity among workers, addiction treatment and criminal justice-associated costs), and estimates that the government shoulders around one-fourth of that burden (via Medicare, Medicaid and veterans’ programs)? The government starts to look for more solutions.
The Bipartisan Policy Center proposed reform in a recent report that aims to: “identify barriers to integration caused by federal policy, to identify policy options to mitigate or remove those barriers, and, through policy changes, to advance evidence-based treatment for mental health in the United States.”
“Electronic records help doctors and other providers make better decisions about their patients’ care. Americans who receive substance abuse and mental health treatment should benefit from that technology, too,” said Senator Sheldon Whitehouse (D–Rhode Island), one of the sponsors for similar legislation that cleared the Senate last year. “This bill would test the use of electronic health records by mental health providers to care for patients who too often are left behind.”
This shines a light on behavioral health stigma and related discrimination at even (and most importantly) the fundamental “patient data” level. One could argue that one of the biggest culprits for this data discrimination is the very federal policy enacted a decade ago which was originally designed to “protect” patients’ privacy concerns — quite the paradox, if you think about it.
If all health care reform is designed to put the patient at the center of care, including in even the most challenging behavioral health settings, yet the data conundrums around patient privacy concerns seem like a Catch 22? Consider that one of the world’s first chatbots, introduced in 1964, was … (wait for it) … a therapist.
Advances in “listening” technology touted at CES and HIMSS expand the possibilities that tech could be used to create empathy and foster connection, perhaps chipping away at some of the societal root causes for the suicide rate increase. Not to say that we should expect “more from technology” and “less from each other.” But rather, let’s use technology to learn — and address — more about each other. Thus, advancing our abilities to treat the whole patient, for providers, addiction treatment centers and everyone in between.
“It’s also about the way people approach the entire spectrum of behavioral care,” Milano adds. “How can so many people all be experiencing the same issues, while the majority of the concerns still going unspoken? The more celebrities, and even everyday people, that speak out about mental illness, the more that will hopefully help lift the dark cloud of stigma — the one that always exists regardless of policy shifts — to get addiction and behavioral health patients the treatment they deserve.”