Hearts and Minds

Gastroesophageal reflux disease, or GERD, affects more than 60% of the U.S. population and is one of the single most common causes of hospitalization. It can manifest as anything from an acute but isolated experience of heartburn to a chronic condition eroding the esophageal lining and compounding into all manner of other gastrointestinal and digestive disorders.

Like most diseases, GERD can be attributed in part to genetics, diet, and the copresence of various other conditions, but it is also unambiguously linked to patient mental health. Stress, depression, a spectrum of eating and sleeping disorders, anxiety–in short, any of the most common mental and behavioral health problems we know of–all correlate with gastrointestinal disorders so strongly as to be predictive. They are like salt and pepper–or better yet, the chicken and the egg.

GERD is a particularly useful case study for highlighting a major deficiency in the design and implementation of EHRs, as well as the culture of medicine into which technology is slowly being integrated.

Heal Your Mind and The Rest Will Follow

In a society where “heartburn” is conventional shorthand for any sort of emotional distress, the link between mental health and physical health is already culturally, if not clinically, normative. But the integration of mental and physical health data in patient records, through the EHR, and into the delivery of care, still lags behind our understanding of the link, and its importance to both patient-centered care and population health.

This integration is necessary for both prevention and treatment: from screening and proactive mitigation to calibrating the response and better controlling outcomes (including reducing readmissions, increasing patient engagement, and generally lifting both patient and provider satisfaction). Ostensibly, these areas are key metrics for measuring and pursuing the shift to value-based reimbursement, itself an effort to reign in healthcare costs. Yet their promotion seems too often to come down to technology that was never designed to link mental and physical health records or caregivers.

Better mental health precludes the escalation of common, costly physical health problems. Better EHRs can support the union of these twin pillars of whole-person health, but they aren’t likely to lead the change themselves.

Old Habits

Fragmentation and data silos persist among departments and providers within a single health system, or even a single hospital; this interoperability problem doesn’t get easier when the divide is between mind and body health and the practitioners thereof.

Barriers to interoperability aren’t just in the data layer–they are in the workflow layer, where caregivers think, work, and operate. Making the systems work is part person, part machine, and no amount of deflection will change the fact that people aren’t yet conditioned to fully integrate mental health where it belongs, much less push their EHR systems to support that integration.

If we are going to insist that our EHRs better accommodate and support clinical workflows–rather than billing–we might want to ensure that our workflows reflect the integrated care we need technology to facilitate and advance. This may sound like the chicken and the egg all over again, but the imperative derives naturally from the self-defeating way we’ve constructed our healthcare system.

Coming Home to Roost

The integration of mental and physical health is critical to improving our handling of addictive disorders broadly, and the opioid crisis specifically, because its absence is in part to blame for the genesis of the problem.

The same association visible in GERD patients is behind much of the current opioid crisis, though here it compounds more readily and dramatically into a combination of public health and safety hazards. The neglect of mental and behavioral health in the treatment of physical illness exacerbates more than it heals, and fails the patient altogether. We know it, we see it, and the opioid epidemic allows us to measure it and document it.

Treatment and prevention, in this case, both point to the need for a collaborative systems approach. The more caregivers demonstrate the will and capacity to unify their efforts, the better chance we have of getting developers and programmers to come to the table and make EHRs more clinically viable. There is no lens under which the best way forward is anything other than a push toward greater collaboration and coordination.

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