How the US Army Personalized Its Mental Health Care - Harvard Business Review

The U.S. Army’s efforts to come to grips with a dramatic upsurge in war-related behavioral conditions over the past 13 years holds valuable lessons for bringing precision mental health care to the civilian world.

Virtually everyone realizes that precision medicine, which aims to tailor care to the individual patient’s needs, is essential. Yet in attempts to bring patient-centered, outcomes-based approaches to health care in recent years, mental health has taken a back seat to other areas of medical care. Almost alone among industrialized nations, the United States does not systematically collect data on mental health care outcomes and lacks any nationwide means for harnessing it. Further, the broad range of difficult conditions, competing therapies, and different professions within mental health care have made it seem a poor candidate for the precise assessment, ongoing monitoring, and individualized feedback that are necessary components for making precision medicine a reality.

All three of those essential components of precision medicine are now being addressed in the Army, using a system called the Behavioral Health Data Portal (BHDP). It makes possible the routine collection of patient-reported data using standardized screening instruments, incorporates redesigned patient and care team workflows to allow consistent monitoring, and embeds clinical-decision-support systems for providing individualized feedback and action at the point of care. And it tackles two of the most difficult challenges of ongoing precision care: following patients over time and as they move from place to place and from care provider to care provider.

Between 2003, when the Iraq war began and the conflict in Afghanistan was two years old, the Army’s volume of mental health care visits tripled, from 1.1 million to 3.3 million. Between 2007 and 2011, more than $2.5 billion was spent addressing the problem, yet there was no way to determine whether troubled soldiers were getting better or to more precisely tailor their treatment.

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Against that backdrop, the Army began with hospital-level experiments focused on early and robust screening for behavioral health conditions. The Army’s centralized management team responsible for its behavioral health service line built consensus among Army psychiatrists, psychologists, and licensed clinical social workers on the standard instruments that would be used for screening and follow-up for specific conditions such as PTSD, depression, alcohol use, and for the general assessment of functioning.

Previous efforts at consistent patient screening employed a manual process. Soldiers completed paper forms, which were then scored by support personnel or the care provider. Depending on the responses to the initial screening, soldiers then filled out more forms before or during their session. Such a manual process is labor-intensive and potentially error prone. It also reduces time in session with a provider.

Today when soldiers check in for appointments, they are provided with a laptop or tablet with individualized log-in information. Depending on the nature of the appointment, they complete either a standardized intake screen for their initial appointment or a disease-specific set of screening instruments. This patient-reported data is captured in a HIPAA-compliant manner within BHDP, and the back-end server computes the score and charts progress. Providers log into the BHDP website, where they can immediately see the patient reported data and use the built-in- charting function to visualize progress over time. These data are persistent across geographical locations and can be transferred to other health systems if required when a soldier leaves the Army.

BHDP requires the use of an additional information system because the electronic health record (EHR) system used by the U.S. Department of Defense does not support the capture and visualization of patient-reported mental health care data. Even in the civilian community, EHR software companies have not focused on mental health care, and their use of proprietary architectures has impeded interoperability among different care organizations and thus the portability of patients’ health records.

Early on, providers using BHDP expressed concern about the time required for soldiers to complete the standardized screening instruments before they actually saw the provider. So during initial rollout from May 2012 through February 2014, we examined 80,000 BHDP surveys in four military-treatment facilities. We found that on average it took less than 30 minutes for the first visit and less than eight minutes for a follow-up visit. The appointment process was then modified, with soldiers required to check in 45 minutes before their first visit, and 15 minutes ahead of time for each subsequent visit to ensure that data collection did not reduce face time with the care provider. The Army now routinely collects over 60,000 data points per month, less than 1% of which is incomplete.

Providers also worried that some soldiers misunderstood the questions or misreported their symptoms, calling into question the validity of the data. Consider the case of a soldier who completes a PTSD screening instrument in which she reports trouble remembering important parts of a stressful experience from the past, but is able to vividly reconstruct the experience in her conversations with the provider. The availability of the screening data in real time enables the provider to understand that the soldier has misunderstood the scale, marking 5 for extremely bothered, instead of 1 for not at all bothered. The provider cannot change the patient-reported data but can now incorporate that self-reported information when meeting face to face with the patient, to improve treatment planning and progress tracking.

Even though BHDP collects patient responses and scores the screening instrument, it does not replace the clinical interview; nor does it dictate to care providers the treatments and therapies they should employ. Unlike physical diseases requiring standard lab tests or medical procedures, mental illnesses may respond to a variety of different treatments. Further, the contextual and individual nature of mental illness calls for highly individualized treatment, which is the aim of precision medicine now made possible in the Army by the BHDP’s systematic and consistent provision of actionable data.

The BHDP system has allowed the Army to develop new ways of examining patients and improving the quality of care for key diseases such as PTSD and major depressive disorder. Prior to the introduction of BHDP, it was challenging to examine quality of PTSD care in the Army. It relied on structure and process measures such as access to care and number of visits within an episode of care to act as proxies of care quality. Today, the Army can use the large volume of practice data that is being collected in BHDP to answer the most important question: Do soldiers feel they are getting better? Prior to BHDP, there was no systematic means of collecting and analyzing these data. The notes in the electronic medical record are often a provider’s perception of the effects of treatment, whereas the data in BHDP is purely patient self-reported data.

The benefits of such a system are many, whether in a military or civilian setting: Care providers and patients have a richer, more detailed means of seeing the effects of care. Other members of the care team can see patient progress and ensure other care is consistent with the treatment currently underway. Practice managers can more efficiently and effectively use their providers to meet the needs of their patient base. Health system leaders can identify local best practices and diffuse them across the wider health system. Data on outcomes can be used to develop a comprehensive picture of a health system’s performance. And the volume of data enables better understanding of the progression of diseases at the level of the individual, the provider, the location, and the country.

The Army, of course, enjoys a degree of centralization and a command-and-control structure that makes comprehensive, system-wide improvements more easily attainable than in the civilian system. However, the high cost of health care and the urgency to improve care quality has created significant momentum toward more systematic management of health in the civilian world.

Organizational structures such as accountable care organizations (ACOs) — groups of doctors, hospitals, and other health care providers who come together to manage a patient’s whole health —are a step toward coordinated high-quality care. The implementation of the Affordable Care Act has expanded access to mental health care for over 62 million beneficiaries. This will require health systems to better coordinate, assess, and improve mental health care.

Building a learning health system will require uniform data standards for health information technology and greater interoperability among electronic health record systems as a necessary foundation for delivering coordinated treatment and tracking of patient progress. But even well short of centralization, individual health systems can draw on the Army’s experience to improve precision of mental healthcare. It will require the development of clinical-decision-support systems such as BHDP to capture more precise mental-health-outcomes data, and redesigned clinical-care workflows to protect patient face time with care providers. Health systems can improve on the Army design by incorporating BHDP capabilities directly into the electronic medical record. This combination of clear policy, well-designed technology, and redesigned workflows can come together to enable precision mental healthcare.

The views expressed in this article are those of the authors and do not reflect the official policy or position of the U.S. Army, the U.S. Department of Defense, or the U.S. Government.