Computers in the Consulting Room

When personal computers were introduced to the consumer marketplace in the late 1970s, many considered them to be very expensive toys with limited practical application. Now computers are ubiquitous, and many of us-especially our youngest colleagues-have difficulty in imagining life without them.

Computerized information resources are being introduced into psychiatric practice settings, but some psychiatrists question whether they are really needed. Yet the entire health care system, including psychiatry, is progressively “going digital,” and there seems to be little question that within the coming decade, the vast majority of health care information will be digital.

Although the benefits may not be immediately apparent and there are risks that need to be considered, the adoption of health information technology (HIT) in psychiatric practice is necessary for the optimal integration of mental health care in overall health care service delivery. HIT has the potential to substantially improve quality and efficiency of psychiatric services.

Although many psychiatrists who work in multispecialty group practices, hospitals, community mental health centers, and residential treatment programs are likely to already be using electronic medical record (EMR) systems, many independent psychiatry practices are in a “pre-contemplative” stage of change in regard to the adoption of HIT.

What HIT can do for your practice

Although psychiatrists have lagged behind their colleagues in other fields of medicine in the adoption of HIT in their practices, many are learning the benefits of this technology.¹ Federal government incentive programs have stimulated the implementation of HIT; however, these programs have not been readily accessible to psychiatrists in private practice. Nonetheless, the advan­tages of EMRs and related resources are quite compelling.

Financial. The Agency for Healthcare Research and Quality (AHRQ) has reported substantial savings for practices that implement an electronic health record.² Cost-benefit analyses over a wide range of practice types uniformly show that long-term financial benefits outweigh initial investment costs. Of course, the actual financial impact of an electronic health record may vary according to the size of the practice, the features and design of the technology, the existing overhead structure of the practice, and the effectiveness of implementation.

In psychiatry, for example, an EMR system with efficient use of templates and speech recognition software can eliminate transcription costs and automate various clerical tasks. With the minimal overhead expense of most private psychiatric practices, improvement in the efficiency of clerical tasks can directly reduce uncompensated time and effort of the psychiatrist.

Coordination of care. HIT facilitates communication across specialties and the practice of collaborative care. The adoption of the medical home model across health care has created a critical need for specialists to effectively communicate with primary care physicians. While true interoperability between various HIT products continues to be an elusive goal, there is currently a great deal of momentum in the development of systems for health information exchange, allowing for health information to be transmitted between different EMR systems. This will allow the information to follow the patient as he or she moves between various components of the health care system.

Until these health information exchange systems are implemented, EMR systems can automate the preparation and transmission of clinical information to providers outside of a specific EMR system through secure messaging technology as well as traditional channels, such as fax and regular mail.

Safety. Functions such as electronic prescribing can dramatically reduce adverse drug reactions through alerts regarding drug-drug interactions and can eliminate the problem of typographical errors on written prescriptions.³ EMRs can more effectively bring important safety-related clinical information, such as allergy and adverse drug reaction history, to the attention of the provider in the context of care delivery through rules-based decision support functions. Templates for progress notes in EMR systems offer a framework for the creation of legible, complete, and clinically useful information in the medical record.

Performance improvement. Many practices have documented that appropriate use of technology has led to more efficient workflow.⁴ HIT resources such as patient portals (which allow patients to transmit clinical history forms and rating scales to, and enable secure messaging with, the provider or office) can improve the patient experience and facilitate the incorporation of routine structured assessments of symptom severity into clinical practice. EMR systems may allow providers to develop patient registries to track outcomes and processes of patient care for groups of patients with similar diagnoses to improve the quality of care.

Although concerns about the confidentiality and security of psychiatric information in EMR systems are quite warranted, it can be argued that electronic systems have more robust capacity to protect sensitive clinical information than do paper records.⁵ If rigorously deployed, technological features such as data encryption, electronic audit trails, automated off-site backup functions, and user access controls not only can prevent unauthorized access to information but also can ensure that critical data are not accidentally lost or destroyed. (Editor’s note: please see the Special Report article “New Risks to Confidentiality in the Modern Era” by Dunne and colleagues for more on this topic.)

Choosing the right technology for your practice

With hundreds of HIT products on the market today, identifying the right products for a practice’s needs can be a daunting task. It is good to remember that the “perfect” HIT product simply does not exist, and every product will have its own strengths and weaknesses in the context of the individual practice’s needs. Before getting started with the process of “shopping around” for technology, it is a good idea to understand some of the basic functions of these products.

Products range from all-inclusive “package systems” to “modular pieces” with a single function. While you may be tempted to find a product that meets every one of your needs, many have found that using multiple components to meet fewer needs is also effective. When using modular products, keep in mind that the ability of these products to interface with one another is crucial to a well-run system.

Practice management. Functions such as scheduling, registration, billing, and patient accounts can be found in many stand-alone as well as package products. Some products add the ability to use a computer in the waiting room to gather information from the patient for use during the clinical session. Other functions can include tracking uti­lization review/insurance information and managing informed consent documents.

Communication with patients. Patient portals offer secure methods to allow patients to exchange information with their provider. This is akin to online banking or airline reservations. This evolving field of HIT can enable patients to read or download selected elements of their medical record, such as test reports and evaluation summaries; to request and/or schedule appointments; to personally submit information to the medical record, such as history; to complete assessment measures; and to exchange messages with their provider.

Clinical documentation. This is the “meat and potatoes” of most EMR products. These functions facilitate documentation of the clinical aspects of a practice. Most products offer some form of customizability in the templates used for documentation. Providers should find a level and mechanism of customization that fits their needs.

Some psychiatric products offer the functionality to handle security and access psychotherapy notes uniquely. Integration of rating scales and screens into clinical documen­tation is another potential feature. Many products offer the generation and maintenance of a Problem/Diagnosis list as a function of clinical documentation. Scanning of paper documents can also offer a bridge between traditional “paper-based” practices and the “paperless” office.

Medication management. Various EMR solutions integrate tools to manage medications. Potential features include support for formularies, drug interaction/allergy checking, FDA indication monitoring, and black box alerts. The term “electronic prescribing” refers to the electronic transmission of a prescription order to a pharmacy. This is distinguished from the use of a computer to print a prescription document or to fax an electronic version of that document to a pharmacy.

Federal regulations currently allow electronic prescribing of controlled substances. However, the technological requirements of these prescriptions specify the use of “two-factor authentication” that requires biometric identification or a physical cryptographic key in addition to usual password protection. This, along with more restrictive regulations in some states, has thwarted the complete development of this function.

Reporting tools. Many HIT products can help facilitate the generation of a variety of reports about your practice. Clinical, business, and utilization reports are just a few of the many types of reports this technol­ogy can generate to help summarize the data that are collected by your EMR system.

Technical considerations. Some of the most important characteristics of this technology have to do with the user interface and usability in your practice environment. Various products offer features such as pen and tablet interfaces, mobile access, and a variety of other technical features that may or may not be of use to you. Other important technical characteristics include how the technology is implemented-some systems involve local (on-site) data processing and storage, while others are “cloud-based” systems in which data storage and processing occur on a remote server.

Cloud-based systems are generally associated with much lower initial cost and technical support expense; however, there is often less flexibility and absolute control over the data, and the system depends on a robust and reliable Internet connection. Local systems may be cost-effective for large practices that may be in a position to invest capital resources and can spread the overhead expense across a large group of providers.

Assessing the needs of your practice

The implementation of HIT re­sources may be a substantial, if not the largest, overhead expense for a psychiatric practice. The many decisions involved in configuring a system should therefore be guided by a clear strategic plan for the practice.

Knowing what you need and want is quite helpful. If resources are limited, you may need to prioritize your list of desired features and identify those that are absolutely necessary. In keeping with long-term goals, you may choose a system that allows for features to be added over time and that has the capability to export data if you need to switch vendors in the future.

If your expectations and needs for information technology are modest, you may be able to manage your medical records, accounts, and schedule with a standard office productivity software suite, perhaps supplemented with small-business accounting software. For electronic prescribing, you will need to choose a vendor to securely transmit prescription orders to pharmacies. You will also need to have a security plan in place to protect patient information from unauthorized access, and all information will need to be backed up daily. In addition, if you are in private practice, keeping all the old paper records in a file cabinet may be a satisfactory alternative to scanning all of the paper into the EMR system.

Implementing HIT

The transition to an EMR system is a process that unfolds over time. During the early stages of implementation, everything will take a bit longer than it did on the paper system and you may even regret embarking on this change. But, with appropriate commitment, training, and customization, the efficiencies and benefits will gradually become apparent.

In addition to simply learning how to operate and customize the new technology for your practice, it will also be important to evaluate, and if needed, redesign the workflows of your practice to optimally integrate HIT. New tools often warrant changes in processes that involve not only physicians but support staff as well.

It is important to plan the extent to which EMRs will be used during the face-to-face portion of the visit and to carefully consider its impact on your personal interaction and rapport with the patient. For example, it may be helpful to have the patient present when you are updating the medication list and reviewing and discussing laboratory results and other medical data. If so, will the monitor and keyboard be configured so that the patient can jointly view the information? Do procedures for patients to communicate with you and/or your office staff need to be redesigned to optimally use your new communication tools? The impact of HIT on the patient experience, and especially on the relationship between doctor and patient, is an emerging area of interest in informatics research and a compelling issue for clinical study.⁶

In addition, a plan for maintaining previous paper records needs to be in place. Several options are available: maintaining the availability of paper charts for every patient visit for a specific length of time; archiving the paper records for access on an as-needed basis; and scanning some or all paper records for viewing within the electronic system. Many practices choose a combination of these methods.

Opinions about the implementation of this type of technology vary as widely as the number of HIT products available on the market. Preparation and research can enhance the likelihood that practitioners will realize the potential benefits of a more efficient, cost-effective, and clinically sound practice through technology.

References:

References

1. Moran M. Physician EHR use gains steam, but psychiatrists slow adopters. Psychiatr News. 2011;46(6):7-8.

2. Shekelle P, Morton SC, Keeler EB. Costs and Benefits of Health Information Technology. Rockville, MD: Agency for Healthcare Research and Quality; April 2006. Evidence Reports/Technology Assessments 132. http://www.ncbi.nlm.nih.gov/books/NBK37988. Accessed November 14, 2012.

3. Ammenwerth E, Schnell-Inderst P, Machan C, Siebert U. The effect of electronic prescribing on medication errors and adverse drug events: a systematic review. J Am Med Inform Assoc. 2008;15:585-600.

4. Terry K. Rev up your EHR: how to optimize performance. Learn ways to increase revenue, improve practice efficiency and quality. Med Econ. 2011;88:S4-S6, S8-S9.

5. Barrows RC Jr, Clayton PD. Privacy, confidentiality, and electronic medical records. J Am Med Inform Assoc. 1996;3:139-148.

6. American EHR Partners. http://www.americanehr.com. Accessed October 31, 2012.