Success in promoting population health cannot be achieved unless we are able to engage in true coordination across the health care continuum. In order for clinicians and care teams to provide the best possible treatments for an individual, they need to understand the whole patient. Yet, despite the prevailing focus on population health across the broad health care landscape, existing payer and delivery models neglect nearly all of what takes place beyond the walls of the hospital. Thus, the current delivery system is deeply fragmented with sizeable portions of a patient’s data held in different silos, especially data derived from the interactions people have with behavioral health providers – those that provide services for mental health, addictions, and developmental disabilities. This partitioning of information has resulted in a piecemeal understanding of an individual’s personal health story, as well as the inability of care providers to address the holistic needs of those they serve.
The status quo is particularly troubling, because behavioral health issues are prevalent in the United States. It is estimated that one in five American adults have experienced a mental health issue. Patients associated with high mental health care costs incur 30 percent more costs than other high-cost patients, and adults living with a serious mental illness in the United States die, on average, 25 years earlier than the general population. We also see significant correlations between a variety of chronic illnesses and serious depression. Major depressive disorder is found in 40 percent of cancer victims, 27 percent of diabetes patients and 17 percent of people with heart disease. Depression is truly a debilitating condition which prompts people to make about 8 million doctors' appointments a year, and more than half are with primary care physicians. A related concern is our nation’s alarming suicide rate, the 10th leading cause of death in the U.S.
These figures are sobering, and yet mental health is but one part of the larger behavioral health equation; substance use disorders also afflict a sizeable portion of the U.S. population. A recent five-year study from Columbia University found that nearly 40 million Americans 12 and older meet the criteria for addiction involving nicotine, alcohol, or other drugs. A 2014 report by the Substance Abuse and Mental Health Services Administration (SAMHSA) revealed more than 20 million adults in the U.S. were diagnosed with a substance use disorder, and of these, nearly 8 million had co-occurring mental health and substance use disorders.
Despite these daunting challenges, there is reason for optimism. Recent activity at the federal level to pass or consider legislation focused on expanding access to services and providing more resources for behavioral health providers has been gaining support. In March, The Centers for Medicare and Medicaid Services (CMS) announced it will allow states to request 90 percent enhanced matching funds to help long-term care facilities, behavioral health providers and substance abuse treatment centers purchase interoperable technology. These funds will help more facilities across the continuum of care benefit from health information technology solutions and care coordination initiatives, enabling the creation of a holistic patient story. Additional legislation and executive actions focused on these issues include: Mental Health First Aid Act, Excellence in Mental Health Act, Comprehensive Addiction and Recovery Act, Behavioral Health IT Act, Behavioral Health IT Coordination Act, and recently proposed rule changes for 42 CFR Part 2.
Ideally, a patient should have a comprehensive record containing all relevant health information over their entire life, including behavioral health data. More importantly, that information should be accessible regardless of where care is taking place to produce the best possible outcomes for providers and the patients they serve. To achieve this, we should collectively be working toward three important goals.
First, organizations should be adopting health information technology solutions which enable easier and more frequent communication with all members of a patient’s care team. However, today’s behavioral health providers are not well incentivized to invest in health IT solutions, despite the fact that improved care coordination can often be accomplished through the use of technology. The CMS announcement for additional interoperability funding, possible passage of the Behavioral Health IT Act, and the creation of partnerships between larger health care entities and community behavioral health providers, could all significantly accelerate the adoption of new technologies aimed at facilitating care coordination.
Second, we should be encouraging changes to federal and state rules which serve as roadblocks to integrated care, as well as changes to the current incentive structure in favor of a more functional quality-based model. Antiquated federal rules and the patchwork system of state laws around privacy, particularly related to those receiving behavioral health care, undermine the well-intentioned goal of population health. Similarly, quality of care and outcomes should be driving how providers are reimbursed, not conventional fee-for-service models.
Third, and most importantly, when sufficient technology and incentive structures are in place, and legal burdens which restrict the sharing of information are lifted, the focus should shift to improving communication and using personal health information in a clinically actionable manner. Fundamentally, we need to treat the whole person and share information across venues and streams of service so clinicians, care teams, patients and their support networks are able to engage with one another, in coordination, toward the holistic care of each individual. Only then will we be able to achieve the Institute for Healthcare Improvement’s Triple Aim, centered on improved care and satisfaction for patients, positive population health outcomes and a reduction in costs.
Many of Cerner’s clients are well on the road to establishing themselves as centers of excellence for integrated care. The Centre for Addiction and Mental Health (CAMH), Canada’s largest mental health and addiction academic hospital, is one shining example of how an organization can achieve remarkable results through the power of care coordination. CAMH rose from the bottom 10 percent in adoption of advanced clinical information technology to the top 1 percent after they implemented Cerner’s electronic health record (EHR). But more importantly, using this system, all care team members are now able to access the unified health record of each patient, whether the individual shows up at the emergency department, is admitted to an inpatient unit or is simply attending an outpatient clinic visit. Through the use of technology, CAMH is better able to place the patient at the center of care and engage in comprehensive care coordination.
Similarly, Carolinas HealthCare System was recently awarded with the Excellence in Health Information Technology Award from the National Council for Behavioral Health. This prestigious award recognizes Carolinas’ innovative use of technology and the EHR system to support an advanced process designed to facilitate telepsychiatry and improve appropriate patient placement across their entire health system. The deployment of this model has also made a significant impact on reducing average ED length of stay by more than 50 percent. Carolinas has been able to achieve a new level of integration in care delivery for an increasing number of patients with behavioral health needs.
Both of these examples are emblematic of the power of integrating behavioral health into the larger health care apparatus. They should serve as a reminder of how we are best able to provide the finest care and produce some of the greatest outcomes possible when we consider the whole person. This is why Cerner’s vision for 2020 is a system which further integrates all venues and disciplines of care together, making it easier to share important information, so clinicians and care teams can focus on coordinating care to the benefit of those they serve.
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