E-Health and the Transformation of Mental Health Care

This month’s issue highlights important research milestones regarding e-health technologies and their potential to enhance access to psychosocial interventions and improve outcomes for persons with mental disorders. Hunkeler and colleagues conducted a randomized controlled trial of an Internet-delivered chronic care model for persons with chronic depression enrolled in a staff-model health maintenance organization. The program involves a Web-based self-management program supported by electronic medical record–enhanced panel management and provider decision support. Deen and coauthors report on a national assessment of telehealth use in the U.S. Department of Veterans Affairs, which found substantial increases in individual and group telepsychotherapy encounters in recent years. These e-health technologies have great potential to extend the reach of psychosocial interventions beyond the clinic walls, especially for persons in rural settings or who are reluctant to seek mental health specialty care.

Nonetheless, adoption and sustainability of e-health interventions in real-world practice face key challenges. First, it is unclear whether e-health–based psychosocial interventions achieve clinically significant improvements in outcomes that are on par with those of traditional face-to-face interventions. Second, e-health psychosocial interventions have been adopted primarily in staff-model health care systems, which have economies of scale to support electronic medical record systems and nonphysician providers to deliver psychotherapy or self-management support. Third, it is unclear how e-health components will be reimbursed. Under the current fee-for-service system, reimbursement rates for psychosocial interventions are often too low for sustainability or else the reimbursement codes are not billable in primary care, where most patients with mental disorders are seen. Moreover, how will the quality of Web or telehealth interactions be monitored so that reimbursement rates can be established?

The potential for e-health psychosocial interventions to improve patient outcomes will remain unrealized without a concerted effort by health plans, payers, and providers to transform care from a reactive, acute care–based system to a more proactive system based on the chronic care model. Emerging efforts to redesign health systems, such as accountable care organizations and health homes under Medicaid expansion, have the potential to make this transformation a reality. These initiatives should encourage the use of bundled payments to support the infrastructure of the chronic care model, meaningful use requirements for electronic medical records, and patient-centered care strategies. However, these efforts will also need to be coupled with implementation strategies to get e-health psychosocial interventions off the academic shelf and into the hands of consumers. Overall, a combined top-down and bottom-up strategy in which e-health is one of several components will be needed to improve adoption of effective mental health treatments and ultimately improve outcomes for this patient group.