Integrating primary care with mental health care and substance use disorder screening and treatment can help address the growing crisis in mental health while also reducing disparities in care. Using technologies like telemedicine can help promote behavioral health integration, improve outcomes for patients, and advance equity in terms of access to and quality of behavioral health care. But these opportunities also present challenges that policymakers will have to address.
Opportunities to Amplify Behavioral Health Integration Using Technology
Traditionally, the U.S. health system has treated medical and behavioral health conditions separately, resulting in care that is fragmented, of low quality, associated with poor outcomes for patients, and costly to deliver. Despite ongoing efforts, we still fail to deliver care that treats the whole person. Technology can help address this fragmentation while promoting equity by increasing access to behavioral health providers and treatment for patients and improving workflow, including communication among providers.
Increasing access for patients. Telehealth technologies can increase access to care by reducing barriers to in-person visits and allowing patients to match with linguistically and culturally appropriate providers who may be geographically distant but can provide them with person-centered care. Technologies can create linkages to clinician extenders (e.g., care coordinators who can help with health care needs in place of a physician) and to services that may not be available onsite (e.g., behavioral health specialists). There also has been growth in direct behavioral health care through technology. This includes evidence-based interventions such as virtual reality for phobias or virtual cognitive–behavioral interventions for mental health or substance use disorders. Increasingly, these technologies are being adapted for different populations. Taken together, these technologies expand the capacity of the primary care and behavioral health workforce to provide quality behavioral health care to larger numbers of people across diverse geographies. While technologies can enhance access, fundamentally, providers need to be available to oversee and provide the care.
Improving workflow among providers. Health technologies also can support clinical processes and workflows by facilitating triaging of patient issues, offering clinicians decision support in patient treatment, enabling providers to monitor patients’ adherence to medication for mental health or substance use disorders, and digitally tracking and measuring the quality of behavioral health care. Technology also can enable integration of electronic health records (EHRs), allowing behavioral health and primary care providers shared access to patient information. Further, advances in the application of natural language processing allows information to be extracted from medical notes or dictations to populate EHRs and databases used for required reporting, allowing providers to more easily meet quality measurement requirements and lessening their administrative burden. Technologies also enable e-consults, which increase and facilitate communication between primary care and behavioral health providers.
Challenges Posed by Behavioral Health Technologies
While promising, new technologies also present challenges. Technologies are developed and circulated faster than they can be assessed for efficacy, safety, and security. In addition, few innovative digital health solutions directly address the well-documented digital divide. People from lower socioeconomic backgrounds, those in rural areas, or people who lack English proficiency or literacy skills may be unable to access the smartphones or broadband needed to benefit from these technologies. At the provider level, the cost of purchasing, installing, and maintaining health technologies may be challenging for many smaller, underresourced, or rural practices.
Digital technologies also create challenges with respect to privacy because they involve the collection of patient data. Such challenges include
- invisibility: people are unaware of how their data are tracked
- inaccuracy: data may be flawed
- immortality: data have no expiration date and are aggregated over time
- marketability: data frequently are bought and sold, and
- identifiability: individuals can be readily reidentified.
Research and regulation of patient health information must provide an adequate balance between protecting health privacy and the need for collaboration. Unfortunately, current regulatory structures fail to keep pace with rapidly evolving technologies.
Policy Options
The opportunities and challenges identified here exist in a rapidly evolving landscape of technology development. Policies that encourage the development of evidence-based guidelines for the evaluation, adoption, and use of behavioral health technologies can mitigate risk, ensure transparency, and facilitate quality of care and digital health equity. The following strategies can support and strengthen the scaling of technologies:
- Increasing access to broadband through “master internet plans,” like initiatives in New York State and New York City that increase internet access in rural and low-income areas.
- Improving data transparency by clearly communicating data collection and usage practices that also take into consideration the need for sharing information among an integrated team of providers (e.g., the Center for Medicare and Medicaid Services’ and Office of the National Coordinator for Health Information Technology’s Certified Electronic Health Record Technology requirements).
- Strengthening evaluation of technologies; for example, the U.S. Food and Drug Administration’s Digital Health Center of Excellence and enhancing support for supplemental self-certification programs (e.g., the American Psychiatric Association’s App Evaluation Model) to involve technology developers in the evaluation processes.
- Providing additional federal support for research on comparative evaluation and implementation of innovative technologies, particularly for smaller practices and those treating underserved populations.
Given the rapid pace of technology development, it is paramount to identify critical priorities for cooperation and collaboration among policymakers, technology developers, providers, patient advocates, and health insurers. Furthermore, technology developers and providers — with input from patient advocates — need to find a clinically sound balance between in-person contact and technology-base interventions. Finally, the Mental Health Parity and Addiction Equity Act requires parity of insurance benefits between mental health, addiction, and general medical care. The White House recently proposed rules to require health plans to conduct outcome analyses to help ensure adequate access and to use similar factors in setting out-of-network payment rates for mental health and substance use disorder providers as they do for medical providers.
