INFORMATION TECHNOLOGY AND MENTAL HEALTH CARE

RONALD W. MANDERSCHEID

Today’s technologies must help transform overall health care in the United States

Modern information technology (IT) has become ubiquitous in government, business, and personal communication. E-mail, online purchases, filing of tax “forms,” sharing of photos, transmittal of health information, and “library” research all occur at lightning speed. It is hard to remember our lives just a decade ago, when these Internet-driven innovations were not in widespread use.

All of this gives pause for reflection.What impact does the new IT have on our work life, our organizations, our social life, and our community life? Does it drive organizational and societal change—and in a positive way? Based on the rapid-fire changes modern IT is bringing to the workplace and home, we are likely to see continued transformation. In the health care field, as well as the mental health care industry, modern IT may bring about beneficial changes in the way information is shared and the services patients receive.

Unlike any other technology from the past, modern IT changes the essential nature of interpersonal communication. Originally, all human communication occurred on a face-to-face basis in real time. The advent of the written word allowed space/time constraints to be transcended in a narrow way; mail and the telephone allowed them to be transcended on a much broader basis. However, people tended to communicate with others who were known, and who generally shared a common language and culture with the communicator.

In the Internet age, however, this traditional communication paradigm has been altered by a number of changes:
Acceleration—Because communication through IT is instantaneous, much more networking and interaction can take place per unit of time. For example, in less than a minute, I can broadcast an e-mail to several thousand (or million) people, and they can read it and respond. As a result, interactions, negotiations, and decisions can proceed very rapidly. Norms governing propriety in such interactions currently are being developed through actual trial and error.
Equalization—Modern IT also has the capacity to eliminate traditional social and rank distinctions among participants, as communication is fostered through a network rather than a hierarchical structure. With modern IT communication, a homeless person and a president of a large corporation can have equal access to information. This also means that organizational boundaries between private businesses, professional disciplines, governmental units, and countries can be reduced or eliminated in favor of broader patterns of communication.
Disintermediation—Modern IT has the capacity to eliminate intervening persons, groups, and organizations, i.e., “middle men,” from communication and decision loops in favor of direct communication between end users. There is now direct and instantaneous contact between purchaser and producer; constituent and elected official; or health care consumer and physician.

TRANSFORMING HUMAN RELATIONSHIPS

With direct, instantaneous communication, many of the ways in which we interact with others are now changing. Sociologically, all interpersonal interaction is “staged,” with each participant playing a role (albeit imperfectly). Each player has expectations for the roles that will be played by others, that they usually enter and exit on cue, and that they generally respect the cultural norms that define conduct appropriate to the situation. As the new IT continues to alter interpersonal communication, new cultural norms gradually will develop to guide expected roles and responses.

In the health care field, modern IT already is catalyzing changes in the patient/provider relationship. Traditionally, visits to a physician or other health care provider involved first making an appointment with a scheduler. The patient then arrived several minutes before the scheduled appointment, saw the physician for a very short period, tacitly agreed to follow the advice or prescription given by the physician, and perhaps scheduled a follow-up visit before departing. The entire transaction was very sequential and orderly. (If you do not appreciate the cultural force of these arrangements, just try to schedule an appointment on a Sunday morning.)

E-mails between patients and physicians now make it possible to circumvent the structures and cultural norms that define the office visit. E-mails can be sent and replied to 24 hours a day, and other physicians can be copied and made part of specific transactions. Health care information can be exchanged rapidly among caregivers. Professional health care associations are just beginning to evolve norms regarding appropriate electronic interactions between consumers and professionals.

At a slightly more complex level, the physician can incorporate modern IT into an office visit. A health care consumer may interact with a computer to answer a series of questions about personal symptoms and health status before seeing the physician or other health care provider. The physician may use computer programs to assist with diagnosis; the treatments given or the drugs prescribed may be monitored through modern IT; and the charge for the transaction may be generated and mailed automatically.

Other features of modern IT can shape this service relationship. Many medical tests, measuring everything from blood pressure to depressed mood, can be selfadministered at home and the results transmitted immediately via the Internet to a physician. E-mails can be replaced by video streaming that more closely approximates the features of human interaction. It’s not impossible to see a future where at least some of the physician’s tasks are replaced by a “smart system” programmed to impart advice depending upon the pattern of consumer responses.

It is immediately obvious from these examples that modern IT can change dramatically the relationship between a health care consumer and a provider. The scope of the relationship can be broadened, better tools can be used for diagnosis and treatment, and treatment plans and effects can be monitored more closely and accurately.

In the field of mental health, modern IT offers providers a way to overcome one of the major deficits of modern mental health care—the failure to develop and to follow carefully a recovery-oriented, individualized treatment plan for every mental health consumer. The mental health consumer, mental health provider, and other professionals who provide housing, job training, and other support services can develop the plan jointly through a series of interactions on the Internet.Modern IT can be used to check milestones, progress, and effects.

INTER-ORGANIZATIONAL ACCESS

Modern IT also effects great changes in interactions between organizations. Inter-organizational relationships typically are governed by elaborate boundary maintenance efforts designed to preserve the integrity of each organization. In terms defined by sociologist Talcott Parsons more than 50 years ago, these efforts can be described as pattern maintenance functions. Today, one of the side effects of economic globalization is that organizations hire relatively more parttime, temporary, and contract employees to remain competitive. As these people enter an organization, it becomes progressively more difficult to define organizational boundaries. Yet, paradoxically, as organizations feel more threatened by globalization, they are likely to devote more effort to boundary maintenance. This results in the classic problem of “stove pipe” organizations, which suffer from the inability to interact with the environment or to protect boundaries effectively.

In the past, inter-organizational communication occurred according to a hierarchical protocol based upon norms that dictated the appropriate persons to engage in such interactions. For example, a staff person in company A would generate an inquiry for company B. Rather than send the inquiry directly to his/her counterpart in company B, the inquiry would be prepared in the form of a letter from one president to the other. Subsequently, the president of company B would pass the inquiry down to the appropriate staff person, who would prepare an answer, and the communication process would be reversed. This communication path sacrificed efficiency for control and boundary maintenance, in addition to being time consuming and costly.

Now, however, modern IT allows the staff person in health care organization A to e-mail the staff person in health care organization B to close the loop on the care of a patient, handle billing questions, or tackle myriad other issues that could arise between any number of either collaborators or competitors. Acceleration, equalization, and disintermediation all can be in play.Usefully described as a “web” of communication, such patterns can progressively blur inter-organizational boundaries and loyalties.

In the mental health care field, in particular, the development of electronic inter-organizational linkages to permit all mental health, general health care, and social service organizations in a local area to constitute a “virtual” system of care could enhance mental health services. In 2003, President Bush’s New Freedom Commission on Mental Health found widespread fragmentation in mental health services. This fragmentation can leave consumers without appropriate care, while compromising positive health outcomes and contributing to rising overall treatment costs. Initially, overcoming these problems might be as simple as crafting an Internet-based electronic information source on all services available in a local area, and identifying a single electronic point of entry into a virtual system of care. One also could link physicians, other providers, and consumers, so they can consult electronically about the consumer’s individualized recovery plan, or maintain consumer records in a single electronic health record. Necessary care and monitoring could be coordinated across organizations.

Similarly, the transformation of financial practices in mental health care will require moving away from encounter-based claim systems to medical savings and spending accounts that span all institutional sectors necessary for successful care. In mental health, this may include mental and physical health care, psychosocial and vocational rehabilitation, housing, employment, and self-care strategies, among others. Simultaneously, mental health consumers could develop websites that provide information to help them negotiate complex systems of care. Such information as where to go (physically or electronically), whom to see, and how to seek reimbursement is fundamental.

The only feasible way to create medical savings accounts across these diverse programs is to employ modern IT, which could be used to record the accounts and issue vouchers to consumers for needed care. This approach could have the added advantage of giving mental health consumers greater control over how the vouchers are spent. Finally,modern IT seems to be ideally suited to promote accountability through electronic submission of program performance measures and online evaluation of care by consumers. Electronic evaluations by consumers of the services provided by different organizations, and consumer-operated therapeutic chat rooms also could and should be developed in the short term.

TRANSFORMING INSTITUTIONAL SECTORS

These types of technology-driven changes could benefit the entire national health care system, as well as other institutional sectors. In the recent Crossing the Quality Chasm studies, the Institute of Medicine of the National Academy of Sciences presents a compelling case for the transformation of health care in America. In the Institute’s view, the quality of most health care in the United States is fragmented and based on outdated knowledge.

Antiquated financial practices, use of clinical practices with undocumented effects, failure to use modern IT, and lack of accountability have contributed to the poor quality of health care, as well as spiraling health care costs. True reform, according to the Institute of Medicine, must involve transforming each of these four areas, as well as bringing about greater interaction among the thousands of “stove pipe” health care organizations that do not collaborate. The United States has the most costly health care system on Earth, as measured in expenditures per capita, yet only mediocre effects are being achieved. Clearly, modern IT can be an essential ingredient in implementing the transformation strategies identified by the Institute of Medicine. Better professional training, for example, can be achieved through Internet-based coursework.

As many American executives and managers were educated in the pre-IT era, learning-at-a-distance training will need to be implemented to overcome current defi- ciencies in knowledge. Anecdotal information suggests that the public sector lags far behind the private sector in integrating modern IT into leadership and operations.

Acceleration, equalization, and disintermediation can have salutary effects if modern IT is applied in a thoughtful manner. The health care and mental health care systems will require the careful application of modern IT to be transformed successfully in accord with the vision articulated by the Presidential Commission and the Institute of Medicine. An urgent need exists to apply modern IT to these problems. Our future health and well-being may well depend upon it.

Ronald W. Manderscheid (CC ’83) has worked in all aspects of mental health and has been involved in Cosmos Club community outreach efforts, including child mental health workshops for teachers and counselors from the DC Public School System.

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