Digital Health Will Disrupt Outpatient Care as Usual

Innovations in business can disrupt an industry in different ways. The behavioral healthcare industry will probably be disrupted by the rise of telehealth services, but this is not to say traditional services will disappear. It is more likely that our current configuration of services will change. We will have a broader range of settings and modalities for behavioral healthcare.

New behavioral healthcare products include the monitoring of outcomes as a core feature. Purchasers want evidence of value, and clinical outcomes establish that. These products typically measure change on brief scales like the PHQ-9 for depression or the GAD-7 for anxiety. These new digital or virtual products are often compared to outpatient psychotherapy in terms of effectiveness.

The range of evidence required by purchasers starts from randomized clinical trials of the underlying therapy, moves to efficacy studies for each digitized therapy, and ends with published evidence of the effectiveness of specific new products. For example, cognitive behavioral therapy is quite efficacious, it has been found effective in digital formats, and its use in specific products has been validated.

This chain of evidence is reasonable, and yet it generally does not exist for the real-world practice of its benchmark, outpatient psychotherapy. It is rare for outpatient psychotherapists, practicing either alone or in clinics, to measure their results. Some might argue that trained, licensed clinicians do this work, and all we need to know is that they use validated techniques.

This might make sense for something as straightforward as dispensing a pill. Yet therapy is complex and results vary by provider. Knowing the outcomes for a clinician or a clinic is likely to become increasingly important. The market could one day demand positive outcomes at the lowest possible cost. Should the U.S. healthcare cost bubble burst, a cost-driven marketplace could appear quickly.

What happens then? Outpatient clinics in their current state could cease to exist once cost becomes a prime consideration. Some people could be better served with new modalities that are inexpensive and accessible. An efficient system would be predicated on bringing everyone potentially needing care to clinical attention and then getting people to the right setting and care modality at the lowest cost.

A powerful (and available) way of bringing everyone potentially needing care to clinical attention is through the primary care setting. People seen at least annually in that setting could be screened by a behavioral healthcare professional. This clinician could treat or refer as needed. Some people might benefit from digital or virtual services, others from brief interventions in that setting.

Our current outpatient clinics might then function as centers of excellence for highly specialized care or more chronic and complex cases. This would call for two types of psychotherapists, those able to engage many patients briefly every day in primary care and those better suited to extended treatment. Each type could be recruited based on clinician preference and measured results.

The measurement and the monitoring of results would become standard in all settings, for all patients. It is the basis on which clinical research has always been conducted, and new products of the last decade seem to be pushing our field to adopt outcomes monitoring on a routine basis. This could push us to make our outpatient delivery system more rational and efficient.

This is a positive step forward from a clinical perspective, and it may be initiated by cost factors, but cost should not always be the driving consideration. This is a bias for many business leaders. For example, there is an inclination to design systems in which everyone starts with the cheapest alternative and progresses to more expensive services if needed.

This seemingly reasonable approach defeats the immense value of having astute clinical minds in a comprehensive setting like primary care. We need therapists to identify the early stages of severe problems. Giving everyone a low-cost intervention is a disservice for many people. We also have a range of lower cost services (e.g., virtual vs. in-person sessions), and a clinician should sort this out.

There should be a clinical rationale for how our industry evolves, and yet market forces are mighty and will push us to react and improvise. Disruption of the status quo can be valuable, and we should always be aware of new products and how the market responds to them. For example, the common thought is that the pandemic accelerated the adoption of digital healthcare products by at least five years.

While the changes imagined here for outpatient care may never happen, new products will ultimately change our field. Outpatient clinics may be grandfathered for a time due to their historical role. Yet empirically validated care will one day be more than a philosophical commitment. The standard of care will be for all of us to show evidence of outcomes, not just an appreciation for early validation studies.

Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.