When your therapist is a piece of software

In 2014, Milwaukee-based Froedtert & the Medical College of Wisconsin health network, which operates three hospitals in eastern Wisconsin, saw its standard way of delivering behavioral health services wasn't enough to meet the demand. Patients with mild-to-moderate mental health issues would receive a referral to get one-on-one visits with a psychiatrist or psychologist.

Froedtert also recognized that many of its patients who were having difficulty managing chronic illnesses like heart disease and diabetes were also having issues with depression and anxiety.

“We realized that a lot of people that were struggling with chronic disease also had a mental health co-morbidity,” said Michael Anderes, vice president for Digital Health for Froedtert & MCW health network.

It began looking into a digital technology approach for delivering cognitive behavioral therapy (CBT). The goal is to expand the health network's capacity to quickly respond to behavioral health treatment needs.

Here's how digital CBT works. The referred patient after their primary care visit, where they may have gotten a prescription, receives an email inviting them to log onto a website. They then enroll in 8 to 12 weeks of online sessions consisting of question-and-answer modules similar to what a patient might receive during a psychotherapy session.

The patient can move at their own pace, accessing the CBT module at any time by laptop or smart phone. Once a week, a “supporter” checks a patient's progress, and relays their assessment to a care team who can determine whether the patient may be in need of more intensive treatment.

Relatively new to the U.S., digital CBT tools have been widely deployed in countries like Australia, where online CBT programs are offered through the country's universal access healthcare system, and in the United Kingdom through its National Health Service.

They're getting more attention now from U.S. hospitals and health systems, which see them as a way to supplement their effort to integrate behavioral health into primary care settings and overcome a shortage of specialists willing to take their cases. “In the past year it's been a huge trend particular among hospitals and health systems that are moving more and more toward value-based care or taking risk for managing a set of lives,” said John Fryer, a senior consultant with the national healthcare provider consulting firm ECG Management Consultants.

Health systems are being driven to online technologies because they've had to take on more financial risk for the populations they serve. They've discovered many of their patients with multiple chronic conditions, which affect one in two adults and account for 86% of healthcare costs, have underlying mental or behavioral health conditions, which make them difficult to treat effectively.

Untreated depression and anxiety often led to a higher likelihood patients would end up engaging in risky behaviors like smoking, poor eating, lack of exercise, and alcohol and drug use. Those suffering from untreated depression are also less likely to adhere to their medication regimens, which makes manageable chronic conditions more severe and costlier to treat.

Many systems face difficulties in offering mental health services to such patients. Reimbursement is inadequate, and there is a shortage of providers. Others are simply looking for new ways to meet the growing demand.

At Froedtert, it was the latter. As part of a strategic planning process around how to meet the growing need for outpatient behavioral health services, the system decided online CBT programs available in primary care settings might offer a solution, according to Anderes. Later this year, the system plans to pilot an online CBT program in two of its primary care clinics. The online program will be offered to patients who screen positive for mild to moderate depression.

Today a patient visiting a primary care physician for an annual physical examination or coming in for a routine diabetes checkup can also be assessed for depression or other mental disorders, usually by the physician asking a set of screening questions.

Patients using the online CBT program will be able to access it from home via a laptop computer or mobile device. As patients use the tool, their progress will be followed by a care navigator or therapist that can also offer online or telephone support when needed.

Studies have found online CBT therapy can be as effective as an in-person visit with a mental health specialist. It doesn't require travel and they can use the program at any time without cost. It also goes a long way toward eliminating the stigma associated with visiting a therapist.

“It offers an opportunity to get help in a way that feels a little bit more comfortable for some patients,” said Mark Stabingas, executive vice president at UPMC Enterprises. In February, UPMC's venture arm invested $17 million in the San Francisco-based startup Lantern, which has developed an online CBT tool targeted at self-insured employers.

A major benefit of online CBT programs is that they are far less costly than hiring additional behavioral healthcare specialists, who are in short supply. “They [health systems] can roll these platforms out pretty quickly, but the impact can be pretty big in terms of savings if they're able to identity their high-risk populations early on,” Fryer said.

But adoption of online CBT programs has been slow despite its promise and the growing interest among stakeholders. One particular challenge has been overcoming concerns that therapies offered through an online CBT program can provide the same quality of care as an in-person visit for a specialist.

Another roadblock is that healthcare providers are not reimbursed for using online CBT programs. Without that financial incentive, hospital executives without the capital to invest in the new technology and employee training must weigh whether the payback in terms of improved population health management is worth the cost.

“I don't remember if any of these apps or platforms has said 'hey look, we saved $1 million in terms of preventing extra length of stay issues by implementing this program at a 500-bed hospital,” said Dr. Steven Chan, a member of the American Psychiatric Association's Committee on Mental Health Information Technology. “They may have to produce studies like that or do it on a much wider scale if they already are trying to do these pilots.”