Suppose, with the wave of a wand, EHRs became interoperable.
Imagine overnight, physicians and other caregivers became utterly fluid in their communication. The platforms: intuitive, user friendly, and intrinsically helpful. Patients: engaged and attentive through their portals and other forms of access, exercising responsible control over their records. Suppose all the wildest dreams of regulators, providers, technocrats and administrators were realized.
What would come next for digital healthcare?
At best, these would become perfect tools and stakeholders in a deeply imperfect culture. As any management consultant or leadership guru will happily attest, culture is not the sum of your perks, tools, and ambitions. To borrow the definition from Forbes contributor Falguni Desai:
“Culture is the unspoken, but understood, way things are done, the way decisions are dealt, the under currents which determine what gets prioritized and the invisible measure tape by which actions are rewarded. It’s all of the things that are not in the human resource policy manual, but become institutionalized through repeated, yet subliminal reinforcement.”
In the current (and the historical) environment of healthcare, the culture discriminates against behavioral health integration and neglects dietary and nutritional care as a core component of whole-person wellbeing.
For the moment, EHR incentive programs – and, by extension, their development and application – reflect and reinforce this divide between mental and physical health. Physical medicine strained through the cheesecloth of Meaningful Use, and after just a few years of incentives and threats, managed to reach 95% attestation: caregivers have EHRs today, right now. They are struggling to fully integrate them, but that first hurdle has been cleared.
As hospitals and physicians sprint through the next leg of the obstacle course, behavioral health is still languishing in paper and pen records, trying to get a seat at the MU table.
Very recently, even as Meaningful Use is under redevelopment and the new Merit-Based Incentive Payment System (MIPS) gets on deck, funding has been proposed to extend incentive payments to behavioral care providers.
So if adoption is followed by a sorting out of interoperability, would mental health patients have a realistic chance of getting their records utilized by their psychologists and primary care physicians, not just shuffled between them? More than that, would records begin to reflect not just the last 100 years of physical medicine, but the whole-person whose health is documented in the EHR, which includes physical, mental, emotional, and dietary?
One of the governing assumptions seems to have been that by compelling adoption of these new digital tools, America can change the way healthcare is delivered, the way patients engaged with their caregivers, and the way health professionals collaborated along the continuum.
Behavioral health is getting, at least superficially, a long overdue inclusion into this continuum where it rightly belongs. But the underlying assumption has not yet been questioned.
Are new tools the best way to change the culture of healthcare in the United States?
Physicians routinely complain about the intrusion of clunky workflows and excessive clicks in their EHRs. Inclusion of yet more blank spaces for behavioral health data or dietary history could amount to a simple drop in the health data bucket. From a regulatory standpoint, it almost seems like a natural continuation of the logic that brought about the flawed Meaningful Use program.
Compulsory interfacing with these empty sections in an EHR would reflect in the same glaring voids in the practice and delivery of care in the United States and American medical education.
American culture has framed both mental health and diet as personal choices and individual challenges. While one or the other is implicated in virtually all of the major public health crises, chronic diseases, and causes of death in the country, both are relegated to the realm of private choice and retail, rather than vital components of primary care.
They are scarcely touched on within the predominant curricula of medical school, which in turn produces the caregivers who serve as gatekeepers for other specialties and modalities of care. You can hardly hope to have insurance cover your consultations with a nutritionist or a behavioral specialist without a PCP referral.
There is nascent hope that EHRs are changing the nature of health records by raising questions of patient access, visibility, ownership, and control.
Even if a physician is not compelled to enter behavioral health data during every consultation, giving patients access to records devoid of any data on primary mental healthcare is a conversation starter. Same for dietary and nutritional information. When patients see that family health history, medication and prescription records, lab tests, and symptom-trackers are all present and accounted for, but the section covering diet and health are blank, how many might look to their PCPs to start filling in the blanks?
For all the interoperability and use-specific design focus lacking from the behavioral care field, the digital age has not entirely ignored mental health.
We already have sexy new tools, diagnostics, wearables, monitoring, and measuring devices with a laser focus on behavioral health with more, presumably, in the wings. More broadly, a national conversation is slowly gaining steam, talking about the social stigmas insulating mental health from treatment and understanding, and patients from compassionate care.
There is a parallel movement to bring greater dietary information and personal health tracking capacity direct to the consumer. Nutritional advice is proffered by the government routinely, yet still requires a formula for dissemination and interpretation. And on the heels of every official guideline come contrarian studies, and silver bullet superfoods. Patients, as consumers, have demonstrated a large and persistent demand for clarity from a trusted source.
Are EHRs really the most appropriate and effective place for the national conversation to change?
A famous Alcoholic’s Anonymous proverb asserts, “There is no chemical solution to a spiritual problem.” Could it be that, caught up in the rapid transformation and seemingly endless promise of the digital age, we need to remind ourselves that there is no technological solution for a cultural problem?
Interoperability remains a significant obstacle to realizing a modern continuum of care, but so are the cultural barriers between caregivers and their respective specialties. Caregivers, largely, interact with and implement EHRs after their medical education and care delivery practices have been established. To connect the silos that affect human health–individual and population–we may need to look closer to the beginning of the process in medical school to effect real change.
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