PUTTING CLINICAL EVIDENCE TO WORK

In recent years, clinical information technology (IT) and evidence-based medicine (EBM) have played major roles in general medicine, ensuring that care processes are informed by the best, most up-to-date medical evidence and that costs are predictable and appropriate.

Not so in the world of behavioral health. Mental health lags behind general medicine in both IT and EBM for complex reasons, beginning with simple economics: Behavioral health budgets are typically tight and, as a result, clinical IT solutions tailored to this market have been slow to emerge. Additionally, while general medicine has had a sizable body of research upon which to draw for clinical decisions, behavioral health only recently has begun to enjoy the same bounty of EBM resources.

Behavioral healthcare organizations can deliver higher-quality care at lower costs by building EBM into their processes through the use of IT. In general medicine, this combination forms a tool for identifying and stratifying patients, as well as informing case and utilization management decision making. It is time for behavioral health to follow suit.

Identifying the Risk

Let's look at a few of the most important ways that technology can put clinical evidence to work in behavioral healthcare, beginning with analytics: identifying patients who need behavioral health services and stratifying them into severity levels for appropriate treatment. The goal is to prevent symptoms from worsening and requiring more intense levels of treatment.

Early identification could occur when organizations feed medical, behavioral, and pharmacy claims into analytic software that uses built-in algorithms based on EBM. For example, the software could find a patient who is being treated with medication for both diabetes and depression but is not receiving behavioral health services.

Those identified to be at risk in some way can be assessed for the severity of their risk, then stratified according to the level of service they need. Stratification helps guide determination of the most appropriate next steps—for example, whether to enroll a patient in a diabetes disease management program with a strong focus on depression, or perhaps follow up with a more in-depth evaluation by a psychiatrist.

Treating behavioral health issues is simply good medicine, as any endocrinologist who struggles with keeping people with depression and diabetes compliant with their medication and diet regimens will attest. And the return on investment for treatment can be impressive. Just as the presence of general medical conditions can cause behavioral health issues to arise, treatment of behavioral health conditions can have a favorable impact on recovery from general medical conditions, as well as the prevention of further complications. This leads to overall healthcare cost savings.

Empowering Care Management

Case management and utilization management are two more areas in behavioral health in which the combination of EBM and IT can be extremely valuable.

Traditionally, behavioral health has had a “mother may I” dynamic, in which case managers have been cast primarily in the role of permission granters (cost focused) rather than care coordinators (care focused). With EBM tools empowered by IT at their disposal, case managers can resume their seat at the care management table, ensuring that the entire team has access to the best and most current scientific thinking, and that all decisions are made from a common platform.

Take the case of a patient with schizophrenia. Medication compliance tends to be abysmally low among people with schizophrenia. Using EBM, a case manager can look at the evidence about what sorts of medications have the highest levels of compliance, as well as whether side effects or types of social supports might affect compliance, then collaboratively participate with the treatment team to manage the case. Or, at the point of care in a complex psychiatric case, EBM can help guide difficult decisions about the most effective combination of drugs.

Technology comes into play through the use of care management work-flow systems with embedded “smart logic.” Although a variety of federal and other initiatives are bringing the industry closer to a national health information network, which will enable a wealth of patient information to be fed into these work flows via care management systems, the success of behavioral health in using electronic medical record data will rely on the development of a standard nomenclature (standardizing behavioral health clinical data). Once these hurdles to information sharing are overcome, one constant pain for case managers will be solved: how to prioritize the countless issues and problems that confront behavioral health patients. Smart systems empowered by EBM will take the guesswork out of such decisions, enabling case managers to anticipate and react to changes in a patient's care more efficiently and effectively, thereby facilitating better patient outcomes.

Utilization management also can benefit from these smart systems, which can be used to answer two important questions: What is the most appropriate level of care for a patient, and when should he/she move to another care setting? Using the best clinical evidence about the most appropriate care levels for different illnesses and severity levels, utilization managers can better adjust behavioral health patients’ movement along the continuum of care.

Tools for Success

A final word on the use of EBM and IT in the world of behavioral health: In no field is medicine's dual nature as equal parts science and art truer than in behavioral health. The use of EBM and IT will never replace the clinical judgment and human experience needed for the treatment of mental illness. However, their use can lead to more consistent, better informed decision making, lower healthcare costs, and better care outcomes for those who suffer from complex and nuanced issues.