At the University of Colorado, Denver, Dr. Ben Miller researches collaborative care models and private practice redesign. He co-created the National Research Network’s Collaborative Care Research Network. Dr. Miller spoke with HealthBiz Decoded about the divide between mental and physical healthcare, which results in a lack of interoperability for their electronic medical records.
Q: Your job is to help primary care practices integrate mental health, since that’s where many patients are going for mental health care already?
A: That’s right. One of the primary drivers of inefficiency and ineffectiveness in healthcare is fragmentation, which is seen everywhere in healthcare but it’s seen most evidently in the separation of mental and physical healthcare systems.
Basically everything we want to see in healthcare that’s more of a “triple-aim” value, decrease costs, improve outcomes and enhance the patient experience, it cannot be seen unless we fix this huge divide between mental and physical.
If a patient has diabetes and a comorbid depressive disorder that the primary care physician doesn’t take into account, the diabetes is never going to get better no matter how well you treat it. Our bodies don’t operate as if the mind and body are separate, they operate together.
We land right in that sweet spot of helping communities transform the clinical model for delivering these types of services, how to consistently evaluate these services, and taking the data we gather from the users and innovators on the ground and using that to inform policymakers.
Q: Mental health is fragmented from the rest of healthcare, so how can you use EMR to bridge that gap when they have their own problems with interoperability, how does that work?
A: It doesn’t, is the answer. If you look at your mental health communities, often times they have their own electronic medical records system. Sometimes these systems do not have interoperability within larger medical systems or even connectivity to physical health systems. There are a lot of reasons that I would say stem from the mental health system’s inability to pay for some of the systems that are a little more mature and sophisticated, that might have a higher likelihood of connecting.
What behavioral health and mental health crowds will tell you is they were not included in the HITECH Act, they did not receive incentives to buy those medical records, so the ones they are buying are the ones they can afford.
Their rudimentary EMR keep track in “free text” or unstructured notes, which is like composing an email, because historically, their clinical notes have been centered on narrative, “tell me where you came from, what’s gone on, what is your history.”
The medical side has much more structured, discrete field categories. Blood pressure is a relatively static field that’s easy to extract data from. It’s easier to extract that data and learn more about the patient and about how effective we are in the community with delivering care.
Fragmentation is wholly perpetuated by these two systems that aren’t connecting at all, that are growing in parallel, that’s really making it more difficult for the patient to get the proper care.
Q: Is there a way to fix the problem moving forward?
A: I think the solution is to align and integrate clinical models so we are not delivering care in silos. Say you have a psychologist working on a team in primary care, delivering mental health interventions, who can be working within the same EMR system as the primary care provider.
EMR do support collaboration when providers are working within the same record. We may ultimately figure out how to have medical records connected across practices in the cloud somewhere, but even then you have to ask yourself are the data being extracted into the cloud even relevant for clinical care?
Q: So the solution isn’t actually that complicated; just get providers to work together more, and the records will follow?
A: The primary care provider needs to learn how to speak mental health, and vice versa. You have to be bilingual. Neither of them grew up together, they encountered each other late in life, but it’s not too late.
In some of our communities we actually provide practice coaches, people whose job is to literally hold hands and help people see how they can connect some of the dots and learn to work together.
Unfortunately, a lot of practices that try to do this by themselves, even if they are held accountable, they fail, because of how challenging it is. That’s where we come in. Here in Colorado we’ve found that some of the most well-intentioned practices fail because they don’t have the adequate infrastructure or the adequate outside support system.
Q: What mistakes are the failing practices making?
A: A lot of the time they’re only tackling one part of the problem and not all three: clinical, operational and financial. They’ll change the operational system of how care is delivered but they won’t change the payment system, and the effort fails.
Q: What advice do you have for providers dealing with this transition?
A: Healthcare is increasingly starting to look at how effective they are as providers, and they are going to want to figure out how to address the comorbidities that come along with every single patient they see, and figure out how to address mental health in populations with chronic disease.
The EMR is an enabler – it supports the delivery of comprehensive team-based care – but in and of itself it is not the answer. If we could snap our fingers and tomorrow have an EMR system that was interoperable, would that solve the problem of fragmentation? No. At the clinical level, we’re still treating the pieces instead of the wholes.
Moving toward EMR systems that have patient portals, that allow us to connect to our patients in real-time, those are game changers and I think providers will be hearing a lot about that.