Numbers—there are too many, and we should get rid of some! But behavioral health clinicians, as well as other medical providers, live in an Information Age where the world is rapidly being quantified, digitized, and put online, and technology is leaping ahead into almost magical realms. The demand for health care reform and accountability is a powerful driving force for transferring and innovating technology into quantified medical terms. It seems likely that the future will hold a few more numbers for the clinicians who are a part of the clinical triad of consumers, providers, and insurers. Each member of the triad has similar, and differing, agendas (Krohn, 2010).

The quantification trend in behavioral health began innocently enough, with simple intelligence tests and personality inventories, and is now evolving into a complex constellation of available assessments (Bauer, 2010). These bits and pieces have not yet been blended into a single resource that successfully incorporates them into a meaningful locale such as a “cyber medical home.” Perhaps the sheer number of new choices for assessment, with varying degrees of merit, has caused medicine to lag behind other fields in adopting technology.

Where the technological innovations are evolving is contributing to the confusion of the many technology resources available. As was the case with the Department of Agriculture during the Depression and Dust Bowl days, present-day technological innovations are being developed by smaller groups or individuals (Gawande, 2009). During those days, innovations evolved in small field offices before progressing to the central authority to be distributed throughout the entire network. Likewise, small technology organizations are currently developing solutions in response to needs, and after being assimilated into a larger software concern, these solutions are ready for wider market distribution. Inevitably, they will be incorporated into a larger array of products, called platforms, owned by large corporations, such as Microsoft or Google. When the conglomerate of solutions is blended into a sensible whole, they become more practical to use, but the small innovators will continue as a market presence.

Can we quantify behavior and symptom status? We have been quantifying these assessments in the behavioral health field for a long time. Perhaps the more probing question is, “Is it repugnant to quantify mood states?” And if so, is that a push-back to using new technology? Does the idea of quantifying mood states, for monitoring purposes, perhaps leave you half excited and half anxious? We tend to readily accept quantifying thoughts and feelings in our language, as in, “I feel 100% certain you are a thoughtful reader because you read Annals of the American Psychotherapy Association.”

Does health information technology (HIT) actually work (American Telemedicine Association, 2010)? Often when we think of HIT, we are actually referring to the subfield of telemedicine, which translates readily to behavioral health. The two terms are often used interchangeably. Telemedicine is the transfer of medical information through interactive media for evaluations, consultations, or treatment (U.S. Department of Health & Human Services, 2010). In this article, the focus will be on the specific process of using telemedicine as a method for monitoring symptom status, because of the implications that this particular use presents the field. HIT can be simple or complex, but it has to actually work—and work easily—to be accepted and used. But what does “work” actually mean in this case? The technology should be simple enough that a person can be trained in a very brief time; perhaps learning to use a new technology resource should be no more difficult than learning to access a bank account summary online. Ideally, technology should be intuitive. A brief time getting up to speed puts a clinician in the position of having more clinical data available to perform necessary interventions rather than wasting valuable time on learning another skill set. Let us posit that “work” also means the diminishment of symptoms (J. Shapiro, personal communication, March 13, 2002), or in the case of a chronic condition, “meaningful containment” of symptoms. Being more aware of treatment activity or progress, a clinician can make needed modifications on a timelier basis, which will serve to speed up the treatment plan’s success. Do HIT and telemedicine do this? The Darwinian answer is that if HIT and telemedicine survive as a part of treatment, it will be because they strengthen the treatment process.

Initially, the scientific community embraced information technology, believing it had inherent value and its use in medical applications was assured, but lately we are hearing some dissenting voices. As to the question of whether HIT is effective, some studies seem to say both yes and no (Ledue, 2009), though the White House is supportive of HIT contributions, as indicated by federal funding streams established in the American Recovery and Reinvestment Act of 2009. Nevertheless, the field is evolving, and many unexpected ramifications will come with that evolution.

It appears clinicians who utilize telemedicine may significantly change treatment plans and medication regimens based on the increased amount of information they have available about the course of treatment. These tendencies represent a significant shift in clinical treatment due to using telemedicine as a means of collecting frequent symptom status. A timely and responsive evidence-based treatment approach fits hand in hand with the concept “the more clinical information, the better,” and this is a hard argument to counter. HIT can facilitate gathering and disseminating information easily and cheaply, if done right (Cariello, 2003; Chodroff, 1999; Martinez, Villarroel, Puig-Junoy, Seoane, & del Pozo, 2007).

An extreme minority of clinicians to whom the author has spoken expressed consternation about establishing a technology-based clinical record. Several clinicians actually related a fear that HIT would establish a record for successful malpractice suits. One study has shown that nearly 8% of doctors reviewed ignored “red flags” provided by HIT (Steenhuysen, 2009). Red flags are methods of notification to clinicians that a significant change has occurred with a client under their care. The field will need to come to terms with the willingness of a minority of clinicians to ignore significantly distressing changes in treatment. So, the answer to the question of whether HIT establishes an accountability record: It does. And to increase one’s fear of Big Brother, all the systems available are able to track the number of times a clinician “checks in.” Perhaps clinicians who are uncomfortable with being held accountable for their performance will move out of the field, or out of the state, as evidenced by the findings of Jha (2006) in the research area of provider ratings.

…and More
The two most common concerns about HIT center on its cost—which should be inexpensive or even borne by the insurer which stands to benefit so greatly (Whitten & Buis, 2007)—and its user-friendliness. There are other concerns as well, some genuine and some questionable. Oddly, one of the complaints about subjective client reporting in telemedicine is the concern that the report may be disingenuous, and in a small number of diagnoses, such as borderline personality disorder, this may be a legitimate concern. In the majority of diagnostic categories, reports are found to be reliable, and client reports correlate with the clinicians’ assessments (Sainfort, Becker, & Diamond, 1996). As it stands, simple symptom monitoring and a few well-known assessments will be the areas that will escape controversy in behavioral health, due to the abundance of disreputable Internet-based rating systems that use non-scientific or even blatantly unethical means to assign rankings.

Another concern regarding the use of HIT in behavioral health care centers on privacy issues. The “cyber medical homes” need to be easily accessible and readily available to authorized users, yet paradoxically, the information must be guarded zealously. Few areas of medicine carry the stigma of behavioral health care, so the issue of privacy is extremely important. The increasingly higher standards for encryption of health information will ensure confidentiality, but this raises an interesting question: Will HIPAA limit treatment modalities? Or to put it another way, will the tail wag the dog?

Some consumers may resist investing in their well-being and treatment, so the degree of HIT participation on their part should be minimal to encourage their commitment to care. Will consumers refuse to participate in telemedicine (California HealthCare Foundation, 2010; Piper, 2006)? Possibly. A germane analogy may be the question, “If clients refuse to participate in face-to-face counseling and show a lack of involvement in treatment, have they the right to blame the clinician for a lack of success in treatment?” Studies have shown that consumers like the opportunity to spend time contributing to their care and appreciate feeling like equal partners in the care relationship; they view telemedicine as an “added feature” to benefits, while feeling it is somehow connected to a managed care technique to lower costs—and it is, because it enhances treatment success (Ayantunde, Welch, & Parsons, 2007; Simpson, Doze, Urness, Hailey, & Jacobs, 2001). HIT is adjunctive to care, not a replacement for it.

One major criticism of HIT is that it is confusing and lacking user-friendliness. This is often a problem and a real reason for HIT push-back. Who wants to spend the time training to use a system with the prospect of re-training when the “new and improved” application comes out next year? Technology should be very intuitive, with a minimum of training (Lang, 2010). Quick, easy, obvious.

With regard to cost, can we get reports both frequently and inexpensively? Yes; that is a great benefit of successful telemedicine systems (McCue et al., 1998; Reardon, 2005). However, some systems are overly complicated and require expensive hardware that is not economically viable. In one instance, a Colorado public health care telemedicine initiative failed so miserably that the pilot program was canceled by the state legislature due to poor performance. That is quite an indictment in these trying economic times, given the easily attained benefits of telemedicine technology (Gray, Stamm, Toevs, Reischl, & Yarrington, 2006).

Another concern is the lack of defined reimbursement across insuring plans. It is reasonable to speculate that payment issues will evolve along with the HIT field. Technology can be pricey, but it should be inexpensive. If it is pricey, the manufacturer has not figured out the best approach. Within the triad of the care team (consumer, provider, and insurer), it is arguable that the insurer should fund the technology so that it is easily available to enhance efficient care, provide continuity of care, and thereby contain costs. One symptom-monitoring approach used by the Henry Ford Health System improved care while cutting inpatient re-admission for a limited range of physical health diagnosis 36-68% (Pharos Innovations, 2009). If those figures are translatable to the behavioral health field, it is in the best interest of the insuring bodies to provide telemedicine services. The providers have greater treatment resources using telemedicine symptom-monitoring methods and may specialize in areas where they are more prone to succeed, and the consumer receives improved quality of care. It is a win-win-win for the triad.

“Things to Come”
Aside from the new details and operational rationale of HIT, its much broader implications will subtly change the clinical world. Without our noticing, its ramifications will alter the reality of the clinician. New electronic health records place a great deal of focus on treatment outcome details—what we call a static history. The marriage of those records with dynamic symptom reports will give a fuller clinical picture. These dynamic snapshots, in varying degrees of real time, are becoming popular as they enhance evidence-based medicine and provide better outcomes. In behavioral health, consumer reports are often subjective replies to questions about the consumer’s unique symptoms, captured by telephone, the Internet, or other devices. In other areas of health care, consumers may report with various telemetric devices that are connected to the method of transmission, which add to expense (U.S. Department of Commerce, 2004; Puskin, 2002). These expensive add-ons can be a deal-killer. Due to the inexpensive nature of subjective reports, the behavioral health field has a great opportunity to improve outcomes using less expensive assessment means. One method of assessment for behavioral health is inquiring about germane distressing symptoms on a frequent basis using scales like the Likert scale. By whatever technology the inquiries are made (or as the techies say, the “data is captured”), whether it be by land-line telephone, cell phone, Internet portal, or other handheld device, it can be universally accessible to the clinician if the data is available online (Bauer, 2010). Using the Internet may also increase the timeliness of specialty consultations (Kedar et al., 2003).

Examined in an aggregate fashion, this raw “symptom status” data will be used as a measure of a clinician’s performance, and that means some type of ratings or rankings—but ratings or rankings will only be accurately defined within a single system of assessment and not across multiple systems. The method of rating will necessarily be in relation to a clinician’s peer group (Jha & Epstein, 2006; Jha, personal communication, March 15, 2007) using the same data resources. Using technology, we are able to “drill down into the data” of status reports to identify the specific diagnoses in which clinicians are most proficient and diagnoses in which they are less likely to render effective service. This has obvious implications for referrals, and it provides a sound basis for a clinician to demand performance incentives based on actual, not anecdotal, clinical performance (Schauffler, Brown, & Milstein, 1999).

Dr. Ashish Jha, of Harvard University School of Public Health and Massachusetts General Hospital, is a pioneer researcher in the area of clinician ratings and has come to some interesting conclusions about what happens when an institution evaluates its clinical staff from a data-based standpoint. In one case, he unexpectedly came to the conclusion, based on data, that a well-known institution that considered itself a leader in a specific area of physical health was, at best, mediocre. The institution was left with the question, “Now that we have the figures, what’s next?” Such revelations mean clinical institutions may be looking at reality checks in terms of treatment-team memberships.

Is “grading” clinicians a good idea? Whether or not we as clinicians are comfortable with the idea, or whether this new reality is good business for the insurer, it is a duty we owe to our patients. Clinicians should encourage, support, and participate in enlightened consumerism. Will the ratings be reality-based? Using changing symptom status as a measure and looking at clinical outcomes can impart a greater degree of validity and reliability in rating clinicians than using indirect measures of performance, or even less credibly, anecdotal information. A few charlatan companies promise physician and institutional ratings while trading off a catchy name and questionable data resources. Inevitably, they will fail as credible resources emerge in the market.

A personal anecdote illustrates the importance of a rating to consumers. The author has a sibling whose spouse is suffering from bone cancer, and that sibling asked the author, “Where is the best clinic? Where is the best doctor?” My reply was tragic. I didn’t know where we could find the information or what database could guide us. All I could rely on was the best sales campaigns and who had the most convincing salespeople. And what kind of monster would want to prevent us from knowing which provider would be most likely to save my sibling’s spouse? Ratings quickly become a human need rather than an intellectual exercise in what is comfortable. Your gut tells you we need ratings.

Evolving along with clinician ratings, we will see aggregate data being used to develop new quality-assessment standards (PricewaterhouseCoopers, 2009). Data-based quality assessment standards will be a departure from best-practices guidelines derived from anecdotal resources. The absurdity of relying on a coalition of clinicians relying on clinical inclinations instead of data-based outcomes stretches the imagination. In a discussion about data-based outcomes and anecdotal best-practice guidelines, the author was asked, by the executive director of a large behavioral health organization, “What if HIT outcome data contradicts what we previously believed was the best practice? Does that mean the best-practice guideline was wrong?”

One motivation for the clinician to provide a higher level of quality care using HIT is a better model of reimbursement. The Patient Centered Primary Care Collaborative in Washington, D.C., is one vehicle among many for clinicians to argue the case of compensation. The mission statement of the collaborative reflects that it is a coalition of stakeholders who have joined together to represent caregivers and advance the patient-centered medical home. These stakeholders believe the patient-centered medical home will improve consumer care and the health care delivery system as well as provide a better model for compensating providers. Clinicians would do well to join these advocacy groups.

Perhaps the greatest sea change for medicine and behavioral health will be in the area of data-driven utilization management (UM), aka utilization review (UR) (Whitten, 2007). UM and UR are often used synonymously, though there are distinctions between the two. UM is generally referred to as an evaluation of the appropriateness, effectiveness, and medical need for future services, while UR is more of a historical assessment. Introducing HIT data-driven UM/UR will catapult the art of fiscal review into a science (Merrick et al., 1999; PricewaterhouseCoopers, 2009). Like quality assessment and provider rankings/ratings, UM/UR only seems to make sense within a peer group measured by the same criteria.

Unbelievably, the largest insuring entity in the United States, the Centers for Medicare & Medicaid Services (CMS), has no true method of measuring the effectiveness of what it purchases for health services. But telemedicine is beginning to be used in the system, and a logical evolution will ensue. In private industry, insuring bodies rely on reviewing “high dollar” cases due to the cost-effective nature of reviewing only that handful. With HIT, limited review could conceivably change to almost every case being reviewed. It will become incredibly easy to review the majority of cases quickly and inexpensively. In effect, when clinicians review the ongoing status of a case, they seem to become their own utilization reviewer and make needed changes in treatment that equate to the insurer’s desire to be cost-effective.

One major corporation’s CEO the author spoke with embraced the idea of accountability and data-driven UM (or UR) because it would provide a vehicle to validate his company’s expertise, services, and clinical assessments. At the other end of the spectrum, another executive director stated that he would have his clinicians sabotage any third-party reviewing system. This director is a service provider for CMS who, again unbelievably, is allowed to perform his own utilization review, as is the case in many states in the CMS system (Mercer Government Human Services Consulting, 2006). This begs the question, “How long will large special interest groups be allowed to represent to the regulatory authorities that they are self-policing effectively?” It sends up a red flag when you hear someone willing to falsify a medical record and that falsification of the record is necessary to “sabotage” HIT.

Must clinicians embrace these technology changes? No, but there is the consideration of the “prisoner’s dilemma”: If there is one sure move offered to advance your position, do you take it?

“In times of change, the learners will inherit the earth, while the learned will find themselves beautifully equipped to deal with a world that no longer exists.”
— Eric Hoffer

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