The changing role of statistics and informatics within the mental health field will be determined primarily by how and to what extent the field's overall services are supported financially and politically. This is a sometimes distressing but essential reality to address. Organizations with diminishing (or disappearing) margins/surpluses or even deficits complain loudly about the increasing data requirements they can ill afford to meet. Neither can they afford to ignore those requirements if they want to retain service contracts essential to their survival. Similarly, on a macro level, the mental health field may resist undertaking any new and substantial data collection projects in the wake of continuing public and private sector finding cutbacks for mental health services. Ironically, many of the specific kinds of data the field may object to are essential to making the argument effectively for enhanced funding.

Given this context, it is insufficient for national government to provide only vision, direction and encouragement regarding the role of statistics and informatics. Also needed are varying kinds of support (not entirely monetary) and guidance for the very practical aspects of informatics implementation. These equally important but often conflicting perspectives will be highlighted in this paper.

Mental health care cost management priorities can create incentives that result in barriers to access, consequent underutilization, and both inappropriate and ineffective care. On the other hand, the incentives can be designed to achieve positive goals as well. As managed care penetration into both public and private sector marketplaces continues to increase, purchasers of mental health care benefits require more accountability from their health plans for the cost and quality of services. The impact of these requirements from purchaser, accrediting and regulatory organizations cascades down through managed care plans to provider organizations and, ultimately, to the individual clinician and consumer. The requirements take the form of increasingly sophisticated data reports, which cannot be produced without a substantial infrastructure of fairly sophisticated computer-based information systems and professionals skilled in their use. This undertaking can be enormously expensive, with costs passed onto benefit purchasers in the form of higher premiums and onto consumers in higher copayments, coinsurance and deductibles. Nevertheless, purchasers and consumers demand this set of developments continue in the near future, and at an accelerated pace, while simultaneously complaining that rates are too high.

However, the administrative burden for mental health organizations meeting these requirements can be eased somewhat. Government can help to encourage: I) purchaser, regulatory and accrediting organizations to agree on a common set of performance domains, indicators, measures and measurement methods that are the most demonstrably cost-effective in producing useful in information, 2) information resource centers and technical assistance experts to assist mental health agencies and organizations in selection of the most cost-effective performance measures and their implementation using standardized methodologies for data collection and analysis, 3) formation of clinical, financial and organizational data warehouses to provide data analyses, reports, and benchmarking information for organizations of similar type and size, 4) determination of what types of organizational performance data and in what format are most useful to purchasers and consumers when comparing organizations for evaluation or for selection decisions, 5) new and expense-saving applications of electronic information exchange technology that speed the turnaround time from data collection through analysis to reports for use in quality improvement efforts, and 6) sharing of information regarding recruitment, retention and contracting out of information technology professionals, particularly within public sector mental health agencies, who are essential to design and operate the information system infrastructure necessary to deploy the performance measurement system.

Increasingly, we can expect the aggregation of individual-level treatment processes and their outcomes to be used as forms of organizational-level performance measures. All the challenges (but more so) and suggestions mentioned previously for performance measures apply to short and longer-term outcome measurement.

An additional challenge is to develop tracking systems for treatment processes delivered or withheld. This will help clarify what produced (or failed to produce) positive outcomes, and lead the way to clinical process improvement. Government can encourage the development of a standardized taxonomy of treatment interventions for mental health and co-occurring disorders. It can also encourage the use of data for clinical process and other service delivery improvements by providing an information I resource center with model examples of the most effective improvement methods for a variety of client populations, including both adults and children as well as communities of vulnerable persons with specific needs.

On a system level, it would be particularly valuable to conduct medical cost offset studies. Innovative contracting with purchasers that rewards savings from effective mental health treatment that reduced unnecessary medical utilization may be our best avenue for enhancing mental health funding streams. New approaches to risk sharing can be developed to encompass this possibility.

Purchasers increasingly want assurance that proven treatment methods, when indicated, are consistently deployed. NCQA set standards for the dissemination to providers of practice guidelines and the monitoring of adherence to them in their 1997 MBHO accreditation standards. To implement these standards completely, a taxonomy of mental health treatment interventions is necessary to track what is actually being provided in the field. When deployment of clinical guidelines is combined with treatment tracking and ongoing evaluation through outcome measurement, the mental health field will have an effective way to conduct clinical process improvement. The effort and investment, while to some extent forced through requirements, should yield major gains in terms of greater acceptance and financing. We can expect the focus on practice guidelines to grow much stronger in the near future.

Treatment providers are overwhelmed with the plethora of different forms and data requirements from the varying payor organizations with which they contract. The growth of managed care has generated intensifying concern from consumers regarding the loss of control over the privacy of their treatment information. This situation is widely perceived to be worsening. Government can help by encouraging standards for: unique and confidential consumer identifiers, common data sets for mental health consumer records, and electronic information exchange that truly safeguards individual mental health consumer confidentiality and data privacy. Without these standards, the combination of providers' administrative burden and consumers' data privacy concerns will slow down, if not paralyze, new data collection and analysis initiatives.

Progress in computerization of mental health consumers' treatment records trails behind that in general health care. In line with DHHS initiatives, government should encourage mental health treatment organization efforts to develop privacy-secured computer-based consumer records, standard-setting efforts within the mental health field such as are being attempted by the Mental Health Statistics Improvement Program and the Workgroup for the Computerization of the Behavioral Health and Human Services Record, and closer collaboration between the mental health field and standard-setting groups that focus on physical concerns such as the Computer-Based Patient Record Institute. Special attention will need to be given to confidentiality of records for individuals with co-occurring mental health and substance abuse disorders; CSAT has a special initiative in this area.

The access to treatment providers in some rural areas is problematic due to scarce resources and geographic distances. As a way to address these problems, telemental health services have proliferated rapidly, have been received generally with enthusiasm, and have generated many positive results.

Government should continue its efforts to help find such programs, and to encourage innovative approaches to their eventual achievement of financial self-sufficiency.

Online and telemental health services have become central to the consumer self-help movement, an increasingly common source of adjuncts to treatment, and in some cases a source of primary treatment itself. They are also appearing in many managed care plans. Their spread and use needs to be documented and studied, just as other services are being assessed. The rapidly increasing use of these services are giving rise to a pandora's box of professional, ethical and legal issues. Some state legislatures are beginning to address the legal issues, but it is important that the federal government become involved since these services by their nature often cross state lines. Government may help provide technical advice and support to professional and trade organizations which are now beginning to address related ethical and professional standards issues. This uncharted territory will be a major policy focus as we grow into the 21st century.