Psychiatry and the Meaningful Use of Electronic Health Records Patrick Triplett

Perspectives in Biology and Medicine, Volume 56, Number 3, Summer 2013, pp. 407-421 (Article) Published by The Johns Hopkins University Press DOI: 10.1353/pbm.2013.0028

For additional information about this article http://muse.jhu.edu/journals/pbm/summary/v056/56.3.triplett.html

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Psychiatry and the Meaningful Use of Electronic Health Records

Patrick Triplett

ABSTRACT Use of electronic health records (EHRs) for psychiatric care is on the rise, although the software and the workflow patterns on which the software has been built are often based on non-psychiatric practices. For providers, the transition from paper psychiatric records to electronic ones requires the development of a new set of skills that includes accommodating the physical presence of the computer and performing various forms of data entry, while still managing to carry out the tasks required for psychiatric practice. These changes alter the dynamic of communication, including elements of assessment and treatment that occur between the psychiatrist and patient. EHRs also raise issues of security of records and greater access by patients to providers and their records. Although EHRs promise an abundance of useful data for research and potentially helpful innovations, they also impose a practice pattern on psychiatry that is made to work largely through the efforts of the physician. EHRs do not enhance interactions in the psychiatric examination room, but instead alter the traditional pattern on which the doctor-patient relationship is founded in psychiatry and through which care is delivered. The medium is the message. — Marshall McLuhan (1964)

Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Meyer 4-119, 600 North Wolfe Street, Baltimore, MD 21287. E-mail: [email protected]. The author receives salary support for his role in implementing an electronic record for the Department of Psychiatry at Johns Hopkins Hospital and affiliated institutions. He would like to thank to Drs. Paul R. McHugh and J. Raymond DePaulo for their helpful advice and thoughts on EHRs. Perspectives in Biology and Medicine, volume 56, number 3 (summer 2013):407–21 © 2013 by The Johns Hopkins University Press 407

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UNDERSTANDING MEDIA: THE EXTENSIONS OF MAN (1964), Marshall McLuhan posited that new forms of media bring with them a set of implications beyond the mere content they convey. This idea is contained in the phrase for which McLuhan is best known: “The medium is the message.” As electronic health records (EHRs) proliferate in health-care settings, McLuhan’s observations have salience for all health-care practitioners, and for psychiatry in particular. Proponents of the switch from pen and paper to electronic records suggest the transition should not be problematic. Psychiatrists and other physicians already take notes on paper or by dictation. Recording notes by typing or use of checkboxes, prefilled templates, and other electronic tools of convenience should, it is argued, make the task easier, not more of a burden. The further benefits of immediately accessible records that are easier to read than handwritten notes, not to mention the financial rewards (or avoidance of penalties) from the federal government for adopting an integrated EHR, seem to suggest the move is an obvious one. But there are a number of insidious effects that the transition to an EHR brings which are not accounted for in this reckoning.

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The New Ergonomics of Psychiatry Ergonomics is the scientific study of the efficiency of humans in their working environment. Ergonomics may emphasize the design of objects or may examine the physical environment’s effects on productivity and the worker. The adoption of EHRs fundamentally changes the ergonomics of traditional psychiatric practice. The physical intrusion of the computer and its screen into the patient examination room and the effects on the workflow of seeing patients for psychiatric care with an EHR require a reconciliation, as the transition is not seamless. Studies have demonstrated the impact on physicians’ attention and communication when a computer screen is in the room. In one study conducted in a primary care setting, the computer was noted to become an additional “party” in the visit, attracting the physician’s gaze for around a quarter of the time spent during visits, even up to 42% of some visits (Margalit et al. 2006). The beneficial effects of EHRs noted in this study included more focus during appointments on medical issues and medication use, greater counseling, and more disclosure to the physician of medical issues, although more time spent gazing at the screen also translated into less focus on psychosocial questions and decreased emotional responsiveness by the physician. Not surprisingly, more time spent on the keyboard correlated with less verbal interaction between the physician and patient. An earlier study compared providers first using paper charts who transitioned to using an EHR (Warshawsky et al. 1994). The authors noted a shift in the providers’ behaviors, from using a conversational style of interaction with continuous data recording to a “blocked” pattern in which the physician asked the patient questions, and then turned to focus on data entry, paying little or no attention to the patient. The benefits for psychiatry from 408

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EHRs may be the observed tendency to focus on some of the important patient care fundamentals, such as medication regimens and compliance issues, co-morbid somatic illnesses, and perhaps a more goal-directed approach in addressing screening and parts of the interval history or exam, while possibly minimizing clumsy fumbling through paper charts (Makoul, Curry, and Tang 2001). But the effects of the entry of this third party in the room may have a more profound impact on a psychiatric encounter than it has in the primary care clinic. The focus of a psychiatric visit is often primarily on the psychosocial issues. The empathy and emotional responsiveness of the psychiatrist are a critically important part of the encounter and are often part of the treatment if psychotherapy is being employed. Computer screens in some settings are growing larger to accommodate the ever-increasing complexity of content that EHRs can capture and convey. This expanding intrusion of the screen into the encounter has an impact on interactions with patients, especially when providers’ attention is directed to typing, or even if they are facing the opposite direction. In the Freudian analytic tradition, orthodox practitioners advocated not facing patients in order to allow the patient to use the analyst as a blank screen on which to project or play out past relationships. In that setting, the depersonalization of the interaction is deliberate—but with EHRs, the depersonalization is an unintended side effect. Most psychiatrists now do not practice as the analysts once did. Psychiatrists engage with the patient, take histories, and sometimes perform a focused physical examination. Psychiatrists convey empathy, and they make eye contact. In short, they are still there in the room with the patient. The presence of a video monitor and keyboard can disrupt that dynamic in dramatic ways. In the worst-case scenario, the provider has his or her back turned to the patient while clicking and scrolling through the data points mandated by regulators, insurers, administrators intent on maximizing “meaningful use” dollars, or those imposing purported quality markers or requirements (CMS 2010). One can imagine the narrative section (that is, the part not automatically filled by templated language) of notes getting shorter, failing to catch the descriptive (and ideally succinct) detail that makes for an effective psychiatric record, while the fundamentals of an encounter, the interaction itself (conveying of empathy and support, confronting of ruinous behaviors, and the like) are given short shrift. Preoccupation with the goings-on on the screen also detracts from observation of patient behaviors, speech patterns, and content. Patients and families may perceive this misdirection of attention as indifference or even hostility, although there are no data to date showing decreased patient satisfaction in the psychiatric setting after an EHR is implemented (Stewart et al. 2005). There are also patients for whom turning one’s back can be a safety consideration. With no obvious fix, providers could simply document later in the day or at home, though this obviously diminishes efficiency, something an EHR would ideally enhance. A study on the use of computers in the primary care setting summer 2013 • volume 56, number 3

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suggests that both good and bad habits practiced in the examination room seem to be carried forward when an EHR is introduced (Frankel et al. 2005). The authors note that integration of the computer into the flow of a primary care visit must be further studied. There are as yet no published studies on the effects of computers in the psychiatric encounter, but the distraction of the third party in the room must be accounted for. Ideally, the screen’s impact can be modified: a screen that can be swiveled, lowered, pushed out of the way, even below the patient’s plane of vision when needed, may help, but the standard monitor base is not built for this. Tablets and apps may be less obtrusive, but they often have limited functionality compared to desktop software or are difficult to use due to diminished screen size.

The Importance of Narrative to Psychiatry Implementing an EHR in a setting where paper records were in use forces a consideration of what a psychiatric note really is. Adolph Meyer (1866–1950) and those he trained took exhaustive patient histories and created the template for what became the standard psychiatric history worldwide. Meyer had faith in the idea that a complete accounting of the biological and social influences that had acted on a patient throughout the life course would provide an explanation of both etiological and pathological processes that led to a patient’s presentation for psychiatric care. The collected details, he believed, would also suggest the appropriate treatment. He was uncomfortable with psychiatric diagnoses and generally avoided them; this tendency likely had its roots in his training in neurology and neuropathology, fields in which the disease triad (clinical syndrome, pathological process, and etiology) could more often explain a patient’s symptoms than in psychiatry. Unfortunately, this state of affairs has not changed much since Meyer’s time; for most psychiatric disorders, etiology and pathological processes have not been elucidated. In psychiatry, providers are still highly reliant on narrative to try to capture the details of the patient’s history and clinical syndrome (signs less often than symptoms), in hopes of establishing a diagnosis and prescribing medications (even though the scientific underpinnings of the treatment may be unknown) and other treatment modalities or interventions to alleviate suffering. The exhaustive history still has its place. The process of formulation for psychiatry is an inductive, not a deductive, process. Psychiatrists must begin at ground level and work their way up. It is important to capture a thorough history to get some sense of what is truly troubling patients and then determine the best available resources to redress them.

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Psychiatry Note Quality, and Teaching Concerns For those new to entering notes electronically, an initial, obvious downside is decreased efficiency, as the new system is learned. Underdeveloped or nonexistent typing skills must be honed, or at least modified. Old workflows must be adapted to account for new electronic processes. It is not always a safe assumption that trainees are naturally adept at computer use or will immediately take to new electronic systems (or that senior clinicians are computer illiterates). Until psychiatric practices have been reconciled to the addition of an EHR into patient care, teaching patient care as practiced with an EHR presents a daunting challenge. Most psychiatrists were trained before the widespread adoption of electronic records in inpatient and outpatient care. With no models or accepted guidelines, how do teaching psychiatrists model appropriate behaviors in using the EHR in patient care settings? Preliminary data suggests that an EHR increases efficiency of note completion in psychiatry (Sola, Bostwick, and Sampson 2007). However, the issue of note quality, including an EHR’s utility and effectiveness as a teaching instrument, remains unclear (Bajgier, Bender, and Ries 2012). At academic medical centers, the faculty is tasked with teaching psychiatrists-in-training the fundamentals of psychiatry, including documentation. Computerized templates created as guides or outlines for collecting crucial elements of history can be useful for students and residents, although those with greater detail and close-ended questions that reduce narrative to single-word answers are not (Ventres, Kooienga, and Marlin 2006). With checklists and templates of preloaded, frequently co-occurring symptoms, the relative weight of symptoms can be lost. A templated history also offers no guidance on elements of that history that merit further exploration. Most concerning are efforts to provide a checklist of symptoms that are summed to make a diagnosis, bypassing the critical step of formulation. The sway under which residents and medical students may be held by electronic media should not be underestimated. Keenan, Nguyen, and Srinivasan (2006), in their literature review of EHRs’ impact on medical (including psychiatric) education, cite a study that found internal medicine residents were “influenced significantly by incorrect advice” provided by automated ECG-reading software and tended to follow the incorrect advice offered by a computerized “decision support” system. The residents’ assumption may be that “the computer must be smarter than I am,” and therefore reliable. The problem, especially for psychiatry, is that any EHR templates would have to stop at the point of being outlines for capturing narrative accounts of history and guiding the core elements of an assessment. Simple summation of symptoms to drive diagnosis and treatment is fraught with risk and should not be the educational paradigm for psychiatry. Abraham Verghese (2008) wrote of his experiences with medical residents-

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in-training who had become accustomed to discussing patients in front of their computers, not at the bedside. He worries that “they may come to view internal medicine as a trade practiced before a computer screen” (p. 2749). Though the residents he worked with were smart and talented, they had become overly reliant on the computerized data, missing out on data gleaned from physical examination. A recent study of time use by interns in two internal medicine programs showed they spent 40% of their time at the computer and only 12% in direct patient care (Block et al. 2013). Psychiatry has fewer diagnostic tests than internal medicine and remains highly reliant on the psychiatric assessment. A patient’s psychiatric symptoms and course cannot be as readily reduced to simple data points. Therefore, psychiatrists continue to depend upon narrative, and formulations are critically important. It may even be a small blessing that psychiatry has fewer data points on which to rely beyond those gleaned from face-to-face interactions, as the risk of reducing patient care to what can be seen on a monitor is a potential trap for all medical educators.

A More Meaningful Use? Ergonomics Reconsidered Despite the efficiencies that EHRs promise, including easier access to records, many are finding that EHRs have not improved efficiency in the day-to-day practice of medicine (Brookstone 2013). Some believe that a move to an EHR includes an implicit expectation that physicians will be tasked with further administrative and clerical burdens that have little to do with doctoring. The physician’s role, it is feared, is being dumbed down from its traditional set of tasks to that of data collection. Check boxes and pull-down menus are completed as the patient or family talks on in the background. The open-ended question, so highly recommended to medical trainees, is replaced with directed questions, some of which are part of pre-loaded, computerized decision trees. With more sophisticated software packages, the chief complaint may trigger an automatic set of correlated diagnoses, orders and medications. Features such as these are billed as helpful “cues,” but viewed more cynically, they can unburden the physician of the task of actual thought and deemphasize the more useful and important tasks, including formulation, establishing diagnoses, and choosing treatments. This resistance to having the physician serve as the data entry person is not new: it is mentioned in an Institute of Medicine (IOM) report on patient records first published over 20 years ago (IOM 1997). Physicians’ exposure to their new tasks (and the underlying assumption that they will not question the transition) often comes in the days or weeks leading to the system’s “go-live” date. At the first outpatient office visit, for example, much of a patient’s history must be entered into the new system. Who does this? In many settings, it is the physician. 412

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Citing the IOM report and another source, one study maintains that “data should be entered at its source . . . by the primary user of the record, data should be entered only once, and be accessible to all sections of the computerized medical record system” (Warshawsky et al. 1994, pp. 269–70). However, debate remains over how much clerical work must be included in physicians’ duties. The ideal workflow for an outpatient psychiatric encounter using an EHR has not yet been described. One approach is to engage the patient and computer simultaneously at some point during an appointment (beginning or end) to review any required elements (vital signs review, medications, medical problems, refills), then redirect attention to the patient’s narrative account or the chosen psychotherapeutic modality. For those used to brief medication checks, the transition may be simple; but for many, this represents a big change from current practice. A number of questions arise. Is it OK to type while patients talk? Is it better to wait until after they’ve left? Is there a role for voice recognition software? Is it OK to dictate snippets of narrative or other notes in front of them? Should patients see the screen? What will the patients think of all this? How well do tablets or handwriting-recognition devices work? The answers to most of these questions will vary by patient, provider, EHR, and practice setting, and this suggests a trial-and-error approach is optimal until widespread EHR use is common and best practices have been proposed and field-tested. For now, the AMA (2013) has only proposed broad outlines for integrating EHRs into clinical care. It is possible that the transition to EHRs will spawn the creation of a new role in the practice of medicine, based upon that of the secretary or scribe. The Occupational Safety and Health Administration (OSHA) (2013) uses a broad definition of ergonomics: “the science of fitting workplace conditions and job demands to the capabilities of the working population.” They go on to add that “Effective and successful ‘fits’ assure high productivity, avoidance of illness and injury risks, and increased satisfaction among the workforce.” If physicians are indeed becoming the best-paid data entry specialists in the hospital, savvy administrators might at some point determine that physicians may actually see more patients and provide better care more efficiently if they are unsaddled from a skill set better developed and maintained in other, less expensive employees. The origins of hospital-based social work as a profession may serve as an instructive example. In providing care for patients, Sir William Osler (1849–1919) and others became aware of the encroachment of external, social factors on physicians’ ability to treat disease. Hospital-based social work was born from the recognition that the duties imposed on physicians from outside the hospital are far too time-consuming to be added to their list of tasks and are often beyond the scope of their specialized training. A medical documentation specialist, whose skills would include the collection of text and other materials that best represent the encounter between doctor and physician, while adhering to the ever-growing regulatory requirements imposed by myriad organizations could summer 2013 • volume 56, number 3

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be a great boon to the practice of medicine. Until an electronic fix is created, the gap remains too large to be bridged by physicians’ efforts alone. (There have been vague suggestions of a paradigm shift in the future, but most contemporary EHRs can be quite clunky to operate.) These are tasks better handled by those best trained to perform them.

Security Issues: Front End Historically, psychiatry records have been sequestered behind a layer of security beyond that accorded to other medical records. This practice is driven by the sensitivity of issues discussed between a psychiatrist and patient, and also by the underlying stigma of mental illness and the presumed embarrassment or worse that would result from a breach of confidentiality. Psychotherapy notes are accorded a special status under the 1996 Health Insurance Portability and Accountability Act (HIPAA), which requires these notes must be kept separate from the general medical record and can be released only with the patient’s written consent (HHS 2013). The protection of these notes was further established by the U.S. Supreme Court in its Jaffee v. Redmond (518 U.S. 1 [1996]) ruling. In order for hospitals to meet the “meaningful use criteria” set by the Centers for Medicare and Medicaid Services (CMS), certain core features of an EHR must be in place, including: maintaining an active medication list, maintaining an allergy list, the capability to exchange key clinical information, the protection of electronic health information, the ability to maintain an up-to-date problem list of current and active diagnoses, and others. There are no psychiatry-specific requirements in these criteria and no guidelines on security of psychiatric records. After an incentive period, during which hospitals receive money for adhering to these standards, hospitals will thereafter be penalized for not having an EHR in place with the required elements. EHRs promise ready availability of medical information to providers, and by extension promise to improve patient care. Needed information can be readily accessed in the emergency department or other setting without having to search through paper charts in another part of the hospital or through a series of siloed computer systems. There are scenarios that might give some psychiatrists or other providers pause, however. Many patients would not want a diagnosis of a sexual disorder, substance use problem, or even a personality disorder visible to anyone with access to the EHR. A hospital employee or medical student with one of these disorders might be even more worried. Seemingly neutral information in an EHR might be more revealing than intended. A medication or allergy list, for example, might inadvertently reveal a patient’s diagnosis of substance dependence issues (naltrexone or daily methadone, for example). One study in an academic medical center found significant worries about disclosure of protected health information, both inside and outside the hospital, among

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those who declined to be included in a transition to an EHR, although these patients were a small fraction of all patients in the system (Flynn et al. 2003). There are, nonetheless, some indications that an EHR for psychiatric records may enhance quality and safety. A recent paper, for example, demonstrates a correlation between a psychiatric service having an EHR that is accessible to non-psychiatric providers and lower rates of readmission at seven, 14, and 30 days (Kozubal et al. 2013). Integration of psychiatry into primary medical care and patients’ care generally is anticipated to be part of the ongoing evolution of care delivered in the United States (Katon 2012; Katon et al. 2012; Johnson et al. 2012; Hay et al. 2012). One hopes that as this paradigm shift occurs, stigma related to mental health disorders and treatment will diminish. Inappropriate, deliberate access of patients’ psychiatric records is a tremendous ethical breach, and adherence to this standard should be seen as a cost of citizenship for any provider. Violation of this trust is a serious matter and is usually grounds for dismissal. In many EHRs, policing of employee behavior is driven mostly by a complaint after inappropriate access has occurred. Routine monitoring of access to psychiatric records is the exception, particularly in large institutions. Many EHRs do not have robust software to monitor access patterns by hospital employees, although as the technology evolves, software is better able to detect access patterns to suggest inappropriate use of the EHR. Substance abuse records (or records kept as part of a substance abuse program) are subject to 42 CFR part 2, federal legislation from the 1970s that requires a level of secrecy beyond even current HIPAA-mandated standards. The laws have not been updated to account for the entry of EHRs into medical practice, and thus they still include language about locked filing cabinets, with no mention of computerized records security. Though stigma regarding substance use disorders remains an issue, many of the privacy concerns now covered by HIPAA make parts of 42 CFR part 2 redundant. However, providers of care in substance abuse clinics must still adhere to its strict standards, including tasking providers with worrying about re-disclosure of any information revealed. The focus on re-disclosure of information is driven by concerns that patients might decline to seek needed treatment due to fear of discovery of their problematic drinking or drug use. One could argue that, regarding the treatment of psychiatric disorders, the revelation of protected information could be just as catastrophic and prevent people from seeking needed psychiatric care. 42 CFR part 2 also hinders efforts at creating a nationwide health information network (NHIN) as outlined in an executive order of former President George W. Bush (Connors and Leipold 2009).

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Security Issues: Back End Formal requests for psychiatric records (via signed, HIPAA-compliant release request or subpoena) from an EHR are handled the same way they might be handled with paper records. But many EHRs allow immediate release of records by a provider to a patient. At first blush this would seem useful—providers and patients would have real-time access to information. The downside is that there are times when patients might be harmed by unfettered access to what psychiatrists have written. For patients with problems handling strong emotions and impulsivity (a not-infrequent combination seen in psychiatric practice), revelation of formulations or assessments without the guidance of the psychiatrist to explain and provide context, could, in theory at least, push them into a tailspin and a potentially lethal outcome. In large group or multi-specialty practices, unless there are hard stops or explicit warnings in place to prevent release of psychiatric records, there is risk that well-intentioned or unthinking colleagues might release the records directly to the patient without consulting with the psychiatrist who wrote the note. An alternative is to restrict access to records to only psychiatrists. This approach seems to fly in the face of current trends toward integration of psychiatry into primary care and other fields of medicine. An intermediate step might be to allow access to psychiatric records but provide instruction to non-psychiatrists and warnings about direct release to patients, including such language as part of an acknowledgment that a provider is entering into psychiatric records. If it appears that psychiatric records will be more broadly accessible, it is conceivable that psychiatrists will simply say less in their notes. The potential loss would be in quality and detail of narrative. But non-psychiatrists generally don’t want a lot of extraneous detail anyway. Osler (1932) noted that “There is no more difficult art to acquire than the art of observation, and for some men it is quite as difficult to record an observation in brief and plain language” (p. 340). Psychiatrists who are accustomed to sequestered notes may need to learn a new skill set, in order to create notes that are succinct and appropriately descriptive in their assessments and plans, as well as free of jargon not generally familiar to non-psychiatric practitioners.

Increased Patient Access Many EHRs now allow greater patient access to records and even to physicians. This increased access might include the ability to request appointments or refills or send a message to a provider. There may also be access for patients to parts of the medical record, such as notes or diagnoses. This could give some providers pause, particularly those whose practice is to not disclose the content of notes directly to patients. At least one study of primary care providers’ notes to which patients had access suggests that only a small percentage of patients noted “confusion, worry, 416

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or offense” at the content of their medical records (Delbanco et al. 2012). The authors conclude that given the minimal disruption caused in their study, open notes should be more widely adopted. The degree to which the experience of primary care physicians and open records can be extrapolated to predict how it would work for psychiatry is unknown, but it should not be assumed they are equivalent. Communication of observations and formulations is important throughout medicine, and clinicians must at times give bad or otherwise awkward news. There are terms used in psychiatry that have a pejorative cast, such as borderline or antisocial personality disorder. Disclosure of such a formulation or diagnosis (which might otherwise be hidden in a written record) to a patient through open notes may force psychiatrists into unfamiliar territory. For those who have experienced it, some are able to see a silver lining, in the opening up of discussions about a patient’s problematic behavioral issues (Lewis et al. 2011). However, many may be reluctant to enter into such a discussion for fear of adversely affecting the therapeutic relationship. There are patients for whom greater access to a psychiatrist may represent a temptation for patients to circumvent planned treatments. In a New York Times article, Dr. Richard A. Friedman (2012) of Weil Cornell Medical College describes how easier access for certain patients “may mitigate efforts to develop patience and frustration tolerance, and might encourage a sense of entitlement and an illusory notion of power and control” for patients in therapy for problems maintaining normal relationships or handling strong feelings such as anxiety or boredom. For these patients, greater access to a provider allows the patients’ worst instincts and behaviors to undermine treatment.

EHRs and Research in Psychiatry Recent advances in technology, such as natural language processing tools, allow researchers to convert the narrative content of psychiatric records into data points for large-scale research projects (Perlis et al. 2012). These advances represent a remarkable opportunity to cull meaningful data from the notes of psychiatrists for further study of all psychiatric disorders treated in inpatient and outpatient settings. Clinical data can then be tied with selected variables and outcomes, promising better understanding of the conditions of psychiatric interest. With EHRs, patients may be more easily enrolled in research projects. Patient access portals to EHRs can be used to enroll patients in ongoing studies, questionnaires may be completed from outside the clinic setting, reminders can be sent out, and queries and updates can be sent in both directions. Patients may be asked to complete questionnaires in the waiting room, allowing for direct input of clinical data before seeing a provider, but can, with the patient’s consent, also be included in research studies. Multi-site studies can more easily be completed. The variety and depth of data sets is expanding, including institutional EHRs across hospitals, claims data, and disease registries. Large data sets summer 2013 • volume 56, number 3

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should allow for large-scale data sharing, but interoperability of EHRs can be problematic, as many have been built as “walled gardens” that inhibit integration of information from different systems (Marsolo 2013). Other emerging technologies, including apps and web-based programs, will allow researchers and providers to collect patients’ self-reported symptoms and observations. Apps may also serve as a conduit for introducing behavioral interventions, such as reminders to introduce greater structure and activities into one’s day for patients with depression, for example. Apps can further be used to monitor activity levels, as indicated through use of text messaging, frequency of phone calls or physical movement as tracked via GPS, giving possible clues to a patient’s mood state. However, as this technology is still in its infancy, concerns have been raised about both privacy and how these data points should be interpreted (Richtel 2012). Data about a person’s genetic sequencing is now more easily obtained, opening up a world of possibilities for research on psychiatric and other disorders. Efforts to link genomic information with phenotypic variables are fraught with a number of problems encountered in EHRs currently, including missing or inaccurate data, and inherent biases that arise in the translation of provided care into an electronic record (Hripcsak and Albers 2013). Linking phenotypes of psychiatric disorders is further complicated by diagnostic reliability issues and dependence on rating scales, which have inherent problems with sensitivity and specificity in defining psychiatric disorders, or the still-developing technology of natural language processing. Even if the problems in linking phenotypes as captured in EHRs with genetic information can be worked out, the stakes of any privacy breaches would seem to be raised. Patients’ fears that insurers, employers, or others would have access to the data would likely be heightened, perhaps past the point at which they would seek needed care for psychiatric conditions.

Conclusion McLuhan (1964) described media as being of two types: “hot” or “cool.” “Hot” media are low in participation and extend a single sense in “high definition” by providing an experience replete with content. “Cool” media require more participation and tend to be “low definition.” As an example, McLuhan compared the content of a photograph (“hot”) to the content of a cartoon (“cool”). Cartoons are mostly outlines and lack the amount of detail found in photos, forcing the viewer’s mind to fill in the rest. At first blush, it would seem that EHRs in medicine are primarily “cool” media: the physician is interacting with the patient and actively entering history and other findings into the computer. But as EHRs evolve, they increasingly have elements of “hot” media: as data in the electronic systems grows, the richness of detail in them increases. Likewise, as the software used in EHRs has

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evolved, there is a drift toward less active participation by the physician. The proliferation of checkboxes, the omnipresent copy and paste feature, and automated decision trees (even when these are disguised as “best practice” guidelines) can have unintended effects on practice. McLuhan claimed that “technological media are staples or natural resources, exactly as are coal and cotton and oil” (p. 21). An EHR does not have to be “the message”: an EHR can and should be a tool that is subordinated to the task of patient care. There are some signs of success in integrating new technologies into the care of patients in general medicine that one can hope will also take hold in psychiatry. The promise of EHRs—their ability to accumulate meaningful and abundant data, to allow more ready access to providers, even to create novel approaches to patient care—are impressive. The task at hand is to assure that this “tool” is put into the service of psychiatry, and not vice-versa.

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Psychiatry and the meaningful use of electronic health records.

Use of electronic health records (EHRs) for psychiatric care is on the rise, although the software and the workflow patterns on which the software has...
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