Changing Policy vs Changing Minds

Guest Editorial

Interoperability is not just a set of technical hurdles, programming considerations, and communication initiatives—though it certainly entails plenty of such challenges.

It is about realizing the much talked-about Continuum of Care, aligning doctors, specialists, nurses, patients, pharmacists—the many individuals and operating environments involved in delivering 21st century whole-person healthcare.

Glaringly absent from popular discussions of this continuum has been behavioral health—those disciplines which focus on the wellbeing of the mind, and manage its influence on every other aspect of personal health.

Behavioral health belongs in this continuum, but has so far faced its own set of challenges in getting to the EHR table.

In a very literal sense, it has been absent from the new digital conception of the continuum of care because it was not included in the Department of Health and Human Services’ Meaningful Use incentive program. Whether this counts as “missing out” on financial assistance or “dodging a bullet” with respect to the onerous attestation requirements, the bottom line is that its exclusion from the MU program reinforces a legacy of exclusion.

Insurance reform under the Mental Health Parity Act and ACA have gone some distance to remedying the marginalization of mental health treatment in American medicine—at least on paper. Reimbursement, as we know, can be the gatekeeper for access, comprehensiveness, and if MACRA is to have its say, quality of care. But before MU is retired, the Department of Health and Human Services (HHS) is recommending its expansion.

In its FY 2017 budget proposal, HHS included language to finally enable certain behavioral health providers to access EHR incentive funds in support of digital upgrades.

“The purpose of encouraging behavioral health providers to get electronic health records is so that we can all be on the same team,” said Andrew Boyd, informatics professor at the University of Illinois at Chicago, of the proposal.

While any MU expansion is big news for the hospitals and small practices that have previously been unable to afford an appropriate platform, the significance–and uphill battle–of such a move goes beyond trading paper records for digital ones.

“Storing behavioral health data in an EHR is a good first step, but we have a culture and policy environment that prohibits this from becoming a reality,” Boyd continued. “Even if we can change policy, changing provider attitudes is going to be even harder.”

The point is well taken.

When we talk about interoperability, often the focus is on the nuts and bolts of sharing data, accommodating the different needs and clinical workflows of various users, and generally redefining health data access and ownership. At least as important to the future of healthcare is hitting RESET on the cultural barriers between behavioral and physical health, ensuring that interoperability serves to better connect professionals—and, by extension, patients, payers, and the whole public perspective on healthcare itself.

Science has gone well beyond demonstrating the critical link between mind and body when it comes to both health, and illness. American athletics in particular are helping to bring this understanding to the mainstream.

Coaches are increasingly responsible not just for the physical conditioning of athletes under their care, but for the mental conditioning which is a key ingredient to performance. Even more aptly, as Ohio University’s Laura Miele explains, is the need for athletes to receive mental rehabilitation as part of their treatment for physical injury:

“If an athlete subscribes to the mentality that they are injury-prone, then there is a high probability for re-injury to occur. In dealing with psychological stress and frustration, an athlete may not play to their pre-injury capacity. The mind and body work together, and if the subconscious is in fear of re-injury, then the body will react, thus potentially putting the player at risk.”
from Psychology Today

That athletic trainers, coaches, and the players themselves are somewhere near the cutting edge of both recognizing and utilizing the mind-body connection is a mixed blessing. It helps bring popular attention to the matter, highlighting the benefits of blended treatment on a larger stage than medical matters routinely enjoy. Conversely, however, it puts that sort of integration on a pedestal; as Miele also points out, popular athletes are held to a higher standard, and in many cases have access to a different standard of medical care.

Ordinary Americans do not enjoy the support and attention of a personal coach; but in joining up providers across the continuum of care, we can turn healthcare into a team activity.

Solving the interoperability challenge takes top priority as an operational matter for obvious reasons. The slow evolution toward quality-based reimbursement may help incentivize it, but there should be little doubt that sheer pragmatism will drive some form of digital information exchange among providers in the near term.

The linking of behavioral health and physical health in the treatment of patients, in their universal EHRs, and their engagement with clinicians from every specialty is not so decisively assured. For all the obstacles that interoperability development presents, here is an opportunity that deserves attention.

When the very infrastructure of healthcare connects mental and physical wellness, the social barrier between the two may finally be broken as well.

Edgar Wilson is an Oregon-based independent consultant who writes on trends in education, healthcare, and public policy.


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