Disruptive Technology Vs. The Disruptive Physician

February 26, 2012

The technological advances of just the last decade—mobile computing, social networking, blogging, tablet computers—were never thought to be “essential” when first introduced.  But while they started as novelties, their advantages became apparent, and today these are all part of our daily lives.  These are commonly referred to as “disruptive technologies”:  upstart developments that originally found their place in niche markets outside of the mainstream, but gradually “disrupted” the conventional landscape (and conventional wisdom) to become the established ways of doing things.

In our capitalist economy, disruptive technology is considered a very good thing.  It has made our lives easier, more enjoyable, and more productive.  It has created no small number of multimillionaires.  Entrepreneurs worldwide are constantly looking for the next established technologies to disrupt, usurp, and overturn, in hopes of a very handsome payoff.

In medicine, when we talk about “disruption,” the implication is not quite as positive.  In fact, the term “disruptive physician” is an insult, a black mark on one’s record that can be very hard to overcome.  It refers to someone who doesn’t cooperate, doesn’t follow established protocols, yells at people, discriminates against others, who might abuse drugs or alcohol, or who is generally incompetent.  These are not good things.

Really?  Now, no one would argue that substance abuse, profanity, spreading rumors, degrading one’s peers, or incompetence are good.  But what about the physician who “expresses political views that are disagreeable to the hospital administration”?  How about the physician who speaks out about deficiencies in patient care or patient safety, or who (legitimately) points out the incompetence of others?  How about the physician who prioritizes his own financial and/or business objectives over those of the hospital (when in fact it may be the only way to protect one’s ability to practice)?  All of these have been considered to be “disruptive” behaviors and could be used by highly conservative medical staffs to discipline physicians and preserve the status quo.

Is this fair?  In modern psychiatry, with its shrinking appointment lengths, overreliance on the highly deficient DSM, excessive emphasis on pharmacological solutions, and an increasing ignorance of developmental models and psychosocial interventions among practitioners, maybe someone should stand up and express opinions that the “powers that be” might consider unacceptable.  Someone should speak out on behalf of patient safety.  Someone should point out extravagant examples of waste, incompetence, or abuse of privilege.  Plenty of psych bloggers and a few renegade psychiatrists do express these opinions, but they (we?) are a minority.  I don’t know of any department chairmen or APA officers who are willing to be so “disruptive.”  As a result, we’re stuck with what we’ve got.

That’s not to say there aren’t any disruptive technologies in psychiatry.  What are they?  Well, medications, for instance.  Drug treatment “disrupted” psychoanalysis and psychotherapy, and represent the foundation of most psychiatric treatment today.  Over the last 30 years, pharmaceutical companies (and prescribers) have earned millions of dollars from SSRIs, SNRIs, second-generation antipsychotics, psychostimulants, and many others.  But are people less mentally ill now than they were in the early 1980s?  Today—just in time for patent expirations!—we’re already seeing the next disruptive medication technologies, like those based on glutamate and glutamine signaling.  According to Stephen Stahl at the most recent NEI Global Congress, “we’ve beaten the monoamine horse sixteen ways to Sunday” (translation: we’ve milked everything we can out of the serotonin and dopamine stories) and glutamate is the next blockbuster drug target to disrupt the marketplace.

Another disruptive technology is the DSM.  I don’t have much to add to what’s already been written about the DSM-5 controversy except to point out what should be obvious:  We don’t need another DSM right now.  Practically speaking, a new DSM is absolutely unnecessary.  It will NOT help me treat patients any better.  But it’s coming, like it or not.  It will disrupt the way we have conducted our practices for the last 10 years (guided by the equally imperfect DSM-IV-TR), and it will put millions more dollars in the coffers of the APA.

And then, of course, is the electronic medical record (EMR).  As with the DSM-5, I don’t need to have an EMR to practice psychiatry.  But some politicians in Washington, DC, decided that, as a component of the Affordable Care Act (and in preparation for truly nationalized health care), we should all use EMRs.  They even offered a financial incentive to doctors to do so (and are levying penalties for not doing so).  And despite some isolated benefits (which are more theoretical than practical, frankly), EMRs are disruptive.  Just not in the right way.  They disrupt work flow, the doctor-patient relationship, and, sometimes, common sense.  But they’re here to stay.

Advances in records & database management, in general, are the new disruptive technologies in medicine.  Practice Fusion, a popular (and ad-supported) EMR has earned tens of millions of dollars in venture capital funding and employs over 150 people.  And what does it do with the data from the 28 million patients it serves?  It sells it to others, of course.  (And it can tell you fun things like which cities are most “lovesick.”  How’s that for ROI?)

There are many other examples of companies competing for your health-care dollar, whose products are often only peripherally related to patient care but which represent that holy grail of the “disruptive technology.”  There are online appointment scheduling services, telepsychiatry services, educational sites heavily sponsored by drug companies, doctor-only message boards (which sell doctors’ opinions to corporations), drug databases (again, sponsored by drug companies), and others.

In the interest of full disclosure, I use some of the above services, and some are quite useful.  I believe telemedicine, in particular, has great potential.  But at the end of the day, these market-driven novelties ignore some of the bigger, more entrenched problems in medicine, which only practicing docs see.  In my opinion, the factors that would truly help psychiatrists take better care of patients are of a different nature entirely:  improving psychiatric training (of MDs and non-MD prescribers); emphasizing recovery and patient autonomy in our billing and reimbursement policies; eliminating heavily biased pharmaceutical advertising (both to patients and to providers); revealing the extensive and unstated conflicts of interest among our field’s “key opinion leaders”; reforming the “disability” system and disconnecting it from Medicaid, particularly among indigent patients; and reallocating health-care resources more equitably.  But, as a physician, if I were to go to my superiors with any ideas to reform the above in my day-to-day work, I run the risk of being labeled “disruptive.”  When in fact, that would be my exact intent:  to disrupt some of the damaging, wasteful practices that occur in our practices almost every day.

I agree that disruption in medicine can be a good thing, and can advance the quality and cost-effectiveness of care.  But when most of the “disruptions” come from individuals who are not actively in the trenches, and who don’t know where needs are the greatest, we may be doing absolutely nothing to improve care.  Even worse, when we fail to embrace the novel ideas of physicians—but instead discipline those physicians for being “disruptive”—we risk punishing creativity, destroying morale, and fostering a sense of helplessness that, in the end, serves no one.

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Big Brother Is Watching You (Sort Of)

February 17, 2012

I practice in California, which, like most (but not all) states has a service by which I can review my patients’ controlled-substance prescriptions.  “Controlled” substances are those drugs with a high potential for abuse, such as narcotic pain meds (e.g., Vicodin, Norco, OxyContin) or benzodiazepines (e.g., Xanax, Valium, Klonopin).  The thinking is that if we can follow patients who use high amounts of these drugs, we can prevent substance abuse or the illicit sale of these medications on the street or black market.

Unfortunately, California’s program may be on the chopping block.  Due to budget constraints, Governor Jerry Brown is threatening to close the Bureau of Narcotic Enforcement (BNE), the agency which tracks pharmacy data.  At present, the program is being supported by grant money—which could run out at any time—and there’s only one full-time staff member managing it.  Thus, while other states (even Florida, despite the opposition of Governor Rick Scott) are scrambling to implement programs like this one, it’s a travesty that we in California might lose ours.

Physicians (and the DEA) argue that these programs are valuable for detecting “doctor shoppers”—i.e., those who go from office to office trying to obtain Rx’es for powerful opioids with street value or addictive potential.  Some have even argued that there should be a nationwide database, which could help us identify people involved in interstate drug-smuggling rings like the famous “OxyContin Express” between rural Appalachia and Florida.

But I would say that the drug-monitoring programs should be preserved for an entirely different reason: namely, that they help to improve patient care.  I frequently check the prescription histories of my patients.  I’m not “playing detective,” seeking to bust a patient who might be abusing or selling their pills.  Rather, I do it to get a more accurate picture of a patient’s recent history.  Patients may come to me, for example, with complaints of anxiety while the database shows they’re already taking large amounts of Xanax or Ativan, occasionally from multiple providers.  Similarly, I might see high doses of pain medications, which (if prescribed & taken legitimately) cues me in to the possibility that pain management may be an important aspect of treating their psychiatric concerns, or vice versa.

I see no reason whatsoever that this system couldn’t be extended to non-controlled medications.  In fact, it’s just a logical extension of what’s already possible.  Most of my patients don’t recognize that I can call every single pharmacy in town and ask for a list of all their medications.  All I need is the patient’s name and birthdate.  Of course, there’s no way in the world I would do this, because I don’t have enough time to call every pharmacy in town.  So instead, I rely largely on what the patient tells me.  But sometimes there’s a huge discrepancy between what patients say they’re taking and what the pharmacy actually dispenses, owing to confusion, forgetfulness, language barriers, or deliberate obfuscation.

So why don’t we have a centralized, comprehensive database of patient med lists?

Some would argue it’s a matter of privacy.  Patients might not want to disclose that they’re taking Viagra or Propecia or an STD treatment (or methadone—for some reasons patients frequently omit that opioid).  But that argument doesn’t hold much water, because in practice, as I wrote above, I could, in theory, call every pharmacy in one’s town (or state) and find that out.

Another argument is that it would be too complicated to gather data from multiple pharmacies and correlate medication lists with patient names.  I don’t buy this argument either.  Consider “data mining.”  This widespread practice allows pharmaceutical companies to get incredibly detailed descriptions of all medications prescribed by each licensed doctor.  The key difference here, of course, is that the data are linked to doctors, not to patients, so patient privacy is not a concern.  (The privacy of patients is sacred, that of doctors, not so much; the Supreme Court even said so.)  Nevertheless, when my Latuda representative knows exactly how much Abilify, Seroquel, and Zyprexa I’ve prescribed in the last 6 months, and knows more about my practice than I do (unless I’ve decided to opt out of this system), then a comprehensive database is clearly feasible.

Finally, some would argue that a database would be far too expensive, given the costs of collecting data, hiring people to manage it, etc.  Maybe if it’s run by government bureaucrats, yes, but I believe this argument is out of touch with the times.  Why can’t we find some out-of-work Silicon Valley engineers, give them a small grant, and ask them to build a database that would collect info from pharmacy chains across the state, along with patient names & birthdates, which could be searched through an online portal by any verified physician?  And set it up so that it’s updated in real time.  Maintenance would probably require just a few people, tops.

Not only does such a proposal sound eminently doable, it actually sounds like it might be easy (and maybe even fun) to create.  If a group of code warriors & college dropouts can set up microblogging platforms, social networking sites, and online payment sites, fueled by nothing more than enthusiasm and Mountain Dew, then a statewide prescription database could be a piece of cake.

Alas, there are just too many hurdles to overcome.  Although it may seem easy to an IT professional, and may seem like just plain good medicine to a doc like me, history has a way of showing that what makes the best sense just doesn’t happen (especially when government agencies are involved).  Until this changes, I’ll keep bothering my local pharmacists by phone to get the information that would be nice to have at my fingertips already.


The Unfortunate Therapeutic Myopia of the EMR

January 19, 2012

There’s a lot you can say about an electronic medical record (EMR).  Some of it is good: it’s more legible than a written chart, it facilitates billing, and it’s (usually) readily accessible.  On the other hand, EMRs are often cumbersome and confusing, they encourage “checklist”-style medicine, and they contain a lot of useless or duplicate information.  But a recent experience in my child/adolescent clinic opened my eyes to where an EMR might really mislead us.

David, a 9 year-old elementary school student, has been coming to the clinic every month for the last three years.  He carries a diagnosis of “bipolar disorder,” manifested primarily as extreme shifts in mood, easy irritability, insomnia, and trouble controlling his temper, both in the classroom and at home.  Previous doctors had diagnosed “oppositional defiant disorder,” then ADHD, then bipolar.  He had had a trial of psychostimulants with no effect, as well as some brief behavioral therapy.  Somewhere along the way, a combination of clonidine and Risperdal was started, and those have been David’s meds for the last year.

The information in the above paragraph came from my single interaction with David and his mom.  It was the first time I had seen David; he was added to my schedule at the last minute because the doctor he had been seeing for the last four months—a locum tenens doc—was unavailable.

Shortly before the visit, I had opened David’s EMR record to review his case, but it was not very informative.  Our EMR only allows one note to be open at a time, and I saw the same thing—”bipolar, stable, continue current meds”—and some other text, apparently cut & pasted, in each of his last 3-4 notes.  This was no big surprise; EMRs are full of cut & pasted material, plus lots of other boilerplate stuff that is necessary for legal & billing purposes but can easily be ignored.  The take-home message, at the time, was that David had been fairly stable for at least the last few months and probably just needed a refill.

During the appointment, I took note that David was a very pleasant child, agreeable and polite.  Mom said he had been “doing well.”  But I also noticed that, throughout the interview, David’s mom was behaving strangely—her head bobbed rhythmically side to side, and her arms moved in a writhing motion.  She spoke tangentially and demonstrated some acute (and extreme) shifts in emotion, at one point even crying suddenly, with no obvious trigger.

I asked questions about their home environment, David’s access to drugs and alcohol, etc., and I learned that mom used Vicodin, Soma, and Xanax.  She admitted that they weren’t prescribed to her—she bought them from friends.  Moreover, she reported that she “had just taken a few Xanax to get out the door this morning” which, she said, “might explain why I’m acting like this.”  She also shared with me that she had been sent to jail four years ago on an accusation of child abuse (she had allegedly struck her teenage daughter during an argument), at which time David and his brothers were sent to an emergency children’s shelter for four nights.

Even though I’m not David’s regular doctor, I felt that these details were relevant to his case.  It was entirely possible, in my opinion, that David’s home environment—a mother using prescription drugs inappropriately, a possible history of trauma—had contributed to his mood lability and “temper dysregulation,” something that a “bipolar” label might mask.

But I’m not writing this to argue that David isn’t “bipolar.”  Instead, I wish to point out that I obtained these details simply by observing the interaction between David and his mom over the course of ~30 minutes, and asking a few questions, and not by reading his EMR record.  In fact, after the appointment I reviewed the last 12 months of his EMR record, which showed dozens of psychiatrists’ notes, therapists’ notes, case manager’s notes, demographic updates, and “treatment plans,” and all of it was generally the same:  diagnosis, brief status updates, LOTS of boilerplate mumbo-jumbo, pages and pages of checkboxes, a few mentions of symptoms.  Nothing about David’s home situation or mom’s past.  In fact, nothing about mom at all.  I could not have been the first clinician to have had concerns about David’s home environment, but if such information was to be found in his EMR record, I had no idea where.

Medical charts—particularly in psychiatry—are living documents.  To any physician who has practiced for more than a decade or so, simply opening an actual, physical, paper chart can be like unfolding a treasure map:  you don’t know what you’ll find, but you know that there may be riches to be revealed.   Sometimes, while thumbing through the chart, a note jumps out because it’s clearly detailed or something relevant is highlighted or “flagged” (in the past, I learned how to spot the handwriting of the more perceptive and thorough clinicians).  Devices like Post-It notes or folded pages provide easy—albeit low-tech—access to relevant information.  Also, a thick paper chart means a long (or complicated) history in treatment, necessitating a more thorough review.  Sometimes the absence of notes over a period of time indicates a period of decompensation, a move, or, possibly a period of remission.  All of this is available, literally, at one’s fingertips.

EMRs are far more restrictive.  In David’s case, the EMR was my only source of information—apart from David himself.  And for David, it seemed sterile, bland, just a series of “check-ins” of a bipolar kid on Risperdal.  There was probably more info somewhere in there, but it was too difficult and non-intuitive to access.  Hence, the practice (adopted by most clinicians) of just opening up the patient’s most recent note—and that’s it.

Unfortunately, this leads to a therapeutic myopia that may change how we practice medicine.  EMRs, when used this way, are here-and-now.  They have become the medical equivalent of Facebook.  When I log on to the EMR, I see my patient’s most recent note—a “status update,” so to speak—but not much else.  It takes time and effort to search through a patient’s profile for more relevant historical info—and that’s if you know where to look.  After working with seven different EMRs in the last six years, I can say that they’re all pretty similar in this regard.  And if an electronic chart is only going to be used for its most recent note, there’s no incentive to be thorough.

Access to information is great.  But the “usability” of EMRs is so poor that we have easy access only to what the last clinician thought was important.  Or better yet, what he or she decided to document.  The rest—like David’s home life, the potential impact of his mother’s behavior on his symptoms, and environmental factors that require our ongoing attention, all of which may be far more meaningful than David’s last Risperdal dose—must be obtained “from scratch.”  If it is obtained at all.


Google Is My New Hippocampus

August 6, 2011

A few days ago, upon awakening but before my brain was fully alert, I was reviewing the events of the previous few days in preparation for the new one.  At one point I tried to remember a conversation I had had with a colleague about three days prior, but I could not quite remember the specifics of our discussion.  “No big deal,” I thought to myself, “I’ll just Google it.”

Almost immediately, I recognized the folly of this thought.  Obviously, there is no way to “Google” the events of our personal lives.  But while impractical, the solution was a logical one.  If I want to know any fact or piece of information, I Google it online.  If I want to find a file on my computer, I use Google Desktop.  All of my email conversations for the last five years are archived in my Google Mail account, so I can quickly find correspondence (and people, and account numbers, and emailed passwords, etc) at the click of the “Search” button.  No wonder I immediately thought of Googling myself.

A recent article in Science claims that the permeation of Google and other search engines into our lives—and now onto our smartphones and other portable gadgets—has not only made it easier for us to retrieve information, but it has also changed the way we remember.  In their experiments, three cognitive psychologists from Columbia, Harvard, and UW-Madison demonstrated that we are more likely to forget information if we know that we can access it (e.g., by a search engine) in the future.  Moreover, even for simple data, we’re more likely to remember where we store pieces of information than the subject matter itself.

The implication here is that the process of memory storage & retrieval is rapidly changing in the Online Age.  Humans no longer need to memorize anything (who was the 18th president?  What’s the capital of Australia?  When was the Six-Day War?), but instead just need to know how to access it.

Is this simply a variation of the old statement that “intelligence is not necessarily knowing everything but instead where to find it”?  Perhaps.  An optimist might look at this evolution in human memory as presenting an opportunity to use more brain power for processing complex pieces of information that can’t be readily stored.  In my work, for instance, I’m glad I don’t need to recall precise drug mechanisms, drug-drug interactions, or specific diagnostic criteria (I can look them up quite easily), but can instead spend pay closer attention to the process of listening to my patients and attending to more subtle concerns.  (Which often does more good in the long run anyway.)

The difference, however, is that I was trained in an era in which I did have to memorize all of this information without the advantage of an external online memory bank.  Along the way, I was able to make my own connections among sets of seemingly unrelated facts.  I was able to weed out those that were irrelevant, and retain those that truly made a difference in my daily work.  This resulted, in my opinion, in a much richer understanding of my field.

While I’ve seen no studies of this issue, I wonder whether students in medicine (or, for that matter, other fields requiring mastery of a large body of information) are developing different sets of skills in the Google Era.  Knowing that one can always “look something up” might make a student more careless or lazy.  On the other hand, it might help one to develop a whole new set of clinical skills that previous generations simply didn’t have time for.

Unfortunately, those skills are not the things that are rewarded in our day-to-day work.    We value information and facts, rather than substance and process.  In general, patients want to know drug doses, mechanisms, and side effects, rather than developing a “therapeutic relationship” with their doctor.  Third-party payers don’t care about the insights or breakthroughs that might happen during therapy, but instead that the proper diagnoses and billing codes are given, and that patients improve on some objective measurement.  And when my charts are reviewed by an auditor (or a lawyer), what matters is not the quality of the doctor-patient interaction, but instead the documentation, the informed consent, the checklists, the precise drug dosing, details in the treatment plan, and so on.

I think immediate access to information is a wonderful thing.  Perhaps I rely on it too much.  (My fiancé has already reprimanded me for looking up actors or plot twists on IMDB while we’re watching movies.)  But now that we know it’s changing the way we store information and—I don’t think this is too much of a stretch—the way we think, we should look for ways to use information more efficiently, creatively, and productively.  The human brain has immense potential; now that our collective memories are external (and our likelihood of forgetting is essentially nil), let’s tap that potential do some special and unique things that computers can’t do.  Yet.


The Virtual Clinic Is Open And Ready For Business

July 9, 2011

Being an expert clinician requires mastery of an immense body of knowledge, aptitude in physical examination and differential diagnosis, and an ability to assimilate all information about a patient in order to institute the most appropriate and effective treatment.

Unfortunately, in many practice settings these days, such expertise is not highly valued.  In fact, these age-old skills are being shoved to the side in favor of more expedient, “checklist”-type medicine, often done by non-skilled providers or in a hurried fashion.  If the “ideal” doctor’s visit is a four-course meal at a highly rated restaurant, today’s medical appointments are more like dining at the Olive Garden, if not McDonald’s or Burger King.

At the rate we’re going, it’s only a matter of time before medical care becomes available for take-out or delivery.  Instead of a comprehensive evaluation, your visit may be an online questionnaire followed by the shipment of your medications directly to your door.

Well, that time is now.  Enter “Virtuwell.”

The Virtuwell web site describes itself as “the simplest and most convenient way to solve the most common medical conditions that can get in the way of your busy life.”  It is, quite simply, an online site where (for the low cost of $40) you can answer a few questions about your symptoms and get a “customized Treatment Plan” reviewed and written by a nurse practitioner.  If necessary, you’ll also get a prescription written to your pharmacy.  No appointments, no waiting, no insurance hassles.  And no embarrassing hospital gowns.

As you might expect, some doctors are upset at what they perceive as a travesty of our profession.  (For example, some comments posted on an online discussion group for MDs: “the public will have to learn the hard way that you get what you pay for”; “they have no idea what they don’t know—order a bunch of tests and antibiotics and call it ‘treated’”; and “I think this is horrible and totally undermines our profession.”)  But then again, isn’t this what we have been doing for quite a while already?  Isn’t this what a lot of medicine has become, with retail clinics, “doc-in-a-box” offices in major shopping centers, urgent-care walk-in sites, 15-minute office visits, and managed care?

When I worked in community mental health, I know that some of my fellow MDs saw 30-40 patients per day, and their interviews may just as well have been done over the telephone or online.  It wasn’t ideal, but most patients did just fine, and few complained about it.  (Well, if they did, their complaints carried very little weight, sadly.)  Maybe it’s true that much of what we do does not require 8+ years of specialty education and the immense knowledge that most physicians possess, and many conditions are fairly easy to treat.  Virtuwell is simply capitalizing on that reality.

With the advent of social media, the internet, and services like Virtuwell, the role of the doctor will further be called into question, and new ways of delivering medical care will develop.  For example, this week also saw the introduction of the “Skin Scan,” an iPhone app which allows you to follow the growth of your moles and uses a “proprietary algorithm” to determine whether they’re malignant.  Good idea?  If it saves you from a diagnosis of melanoma, I think the answer is yes.

In psychiatry—a specialty in which treatment decisions are largely based on what the patient says, rather than a physical exam finding—the implications of web-based “office visits” are particularly significant.  It’s not too much of a stretch to envision an HMO providing online evaluations for patients with straightforward complaints of depression or anxiety or ADHD-like symptoms, or even a pharmaceutical company selling its drugs directly to patients based on an online “mood questionnaire.”  Sure, there might be some issues with state Medical Boards or the DEA, but nothing that a little political pressure couldn’t fix.  Would this represent a decline in patient care, or would it simply be business as usual?  Perhaps it would backfire, and prove that a face-to-face visit with a psychiatrist is a vital ingredient in the mental well-being of our patients.  Or it might demonstrate that we simply get in the way.

These are questions we must consider for the future of this field, as in all of medicine.  One might argue that psychiatry is particularly well positioned to adapt to these changes in health care delivery systems, since so many of the conditions we treat are influenced and defined (for better or for worse) by the very cultural and societal trends that lead our patients to seek help in these new ways.

The bottom line is, we can’t just stubbornly stand by outdated notions of psychiatric care (or, for that matter, by our notions of “disease” and “treatment”), because cultural influences are already changing what it means to be healthy or sick, and the ways in which our patients get better.  To stay relevant, we need to embrace sites like Virtuwell, and use these new technologies when we can.  When we cannot, we must demonstrate why, and prove how we can do better.

[Credit goes to Neuroskeptic for the computer-screen psychiatrist.  Classic!]


When Your EMR Goes Down On You

June 21, 2011

Electronic medical records (EMRs) are the way of the future.  And, for most practices, that future is today, whether we like it or not.  The federal Center for Medicare Services is paying doctors a financial incentive to switch from paper to electronic charts, and the first checks have already been cut.

It’s notable that the government has chosen to bribe doctors to switch to electronic records, when no one had to pay us (or you) to use Google or Facebook or Twitter.  Maybe it’s because EMRs don’t run like Google, Facebook, or Twitter.  Despite the tremendous potential benefits of EMRs, they remain clunky, distracting, and non-intuitive.  In their current form, their benefits are clearly limited to administrators, third-party payers, and others who are more interested in data than in the quality of care provided.  But what do I know, I’m just a doctor, and no one ever asked me.

Anyway, in the last 18 months, I’ve had the opportunity to use two different EMRs, one called Patient Care Manager by Prime Clinical (about which I can’t find much positive to say, so I’ll keep my mouth shut), and another, Practice Fusion.  I must admit I’ve been rather impressed by Practice Fusion, a free “cloud-based” EMR system with many user-customizable features and a surprisingly simple interface.

Alas, for several hours yesterday—right in the middle of a busy Monday—Practice Fusion went down.   As in:  totally unavailable.  Couldn’t log on, couldn’t view any charts, lab reports, patient correspondence, or the daily schedule.  Couldn’t even look at patient demographics.  It was as if the entire chart rooms of hundreds of doctors’ offices across America were closed for the day.

In a conventional practice with paper charts, this sort of thing is unacceptable.  To be sure, things get lost every once in a while, but to lose access to an entire chart room—and schedule—without any idea of when it will return, is a potentially very serious problem.  Doctors have been severely disciplined for losing or missing data (even in individual cases), and clinics have been penalized with significant fines for shoddy recordkeeping.

Fortunately, Practice Fusion came back up late in the day, but not until hundreds of practices across the country struggled for 5-6 hours without vital information, making for a very difficult Monday.

I should point out that (when it works) Practice Fusion is unique.  More so than any other EMR I’ve used, PF is extremely user-friendly, offering informative (and sometimes humorous and irreverent) YouTube videos, live online chat, and an attentive support team.  They even allow comments on their public Facebook page.  You might expect it to be a place for doctors to vent their outrage on a day like yesterday.  To the contrary, most of the comments were quite sympathetic.  Some direct quotes:

“I feel like I’m deaf and blind… could not pull labs or test results…. I know it happens. It could happen even to the best. But hey! It’s not the end of the world!  True, it’s very inconvenient since I’ll be spending most of my evening trying to catch up charting.  But still… Love you guys! Keep up the good work!”

“I love Practice Fusion no matter what happened today… Good job guys!!!”

“We are thankful for PF, even with the RARE problem…. Thanks to you and the team for providing us a reliable and FREE EMR.”

“If it’s going to stay this fast [after the outage] I can get over being down today though it was quite stressful!  Thank you PF staff.  You were probably stressed too.”

It’s a surprising commentary when a very significant glitch in a widely used EMR system—which, in a conventional practice situation, might have resulted in disciplinary action or heavy fines, and which most certainly resulted yesterday in lost income for a number of docs and probably more than a few adverse patient outcomes—was accepted with such grace.

Maybe I’m old-fashioned, but EMRs are not like any other piece of software.  When Netflix goes down, I can’t watch a streaming movie.  But when Practice Fusion goes down, I can’t access vital information which may make a significant impact on the well-being of the patients in my office.  It’s a very slippery slope when we “permit” EMRs to be buggy, and even worse when we providers simply “accept” it (and even give the companies a free pass) when they go down.

But then again, the future is today.  We need to get used to it.


I Want a DSM Wiki

June 8, 2011

As most readers of this blog are well aware, the American Psychiatric Association will publish its latest version of the Diagnostic and Statistical Manual (the hallowed “DSM”) in 2013.  The next version will be version 5.  (Note, it’s “5,” not “V.”  This is so that follow-up versions can be named 5.0.1, 5.1, 5.1.1, etc.  Just like computer software.  I kid you not.)

The provisional criteria have been made public, and the APA invites anyone to comment on its website, dsm5.org.  (The full development process was not this transparent.  Allen Frances and Robert Spitzer, two dissidents, famously decried the “nondisclosure agreements” the book’s authors had to sign.  Spitzer even commented, “The intent seemed to be not to let anyone know what the hell was going on.”)

But as we get closer to the publication date, readers can have a closer look under the hood.  Anyone can surf over to their website and make comments.  Yes, now is your chance to let the leaders of the psychiatric profession know precisely what you think about the new “Somatic Symptom Disorder” diagnosis; challenge the possible removal of the “narcissistic” category; or just tell the authors that you think psychiatry is all a crock of s***.

In an interview published today on Medscape, David Kupfer, chair of APA’s DSM-5 task force, reports that this spirit of openness and flexibility will likely persist even after its publication.  He says the upcoming DSM-5 will be a “living document,” complete with an electronic version (probably online?) which will be “much easier to update and may even include links to videos and vignettes.”

That could be a big step forward.  Imagine: if you’ve never seen catatonia before, you might be able to click on the DSM-5 entry and see a video of a catatonic person.  If your patient doesn’t understand why you just diagnosed her with borderline personality, you can read her a descriptive vignette (so much more interesting than a checklist!) and she’ll get it.

My thinking is, why stop there?  Psychiatrists are already way behind the times when it comes to modern technology.  Our peers in other specialties get to use fancy doodads like MRI scanners and bypass machines and stents all day long.  We just sit around and talk to people.

And then it hit me:  the APA should create a DSM-5 wiki.

For those of you who have no idea what a “wiki” is, it’s a website developed collaboratively by users and visitors.  Any user can add content, and it’s edited in real time by other users.  Disputes are resolved by online discussion, and historical changes can be viewed by anyone.  Perhaps the most famous example of a wiki is Wikipedia, the online encyclopedia.  Those articles were not first published in a book somewhere; instead, they have been written by experts and non-experts alike, and are constantly being edited.  Wikipedia has, for better or for worse, come to replace conventional encyclopedias and is a remarkably accurate (and free) source of material.

Maybe the APA can do the same!  Let’s put the DSM-5 online and let people do whatever they want with it.

Imagine the uses.  A DSM-5 wiki would let clinicians chime in about what they think ought to be changed or added, like an interesting “subtype” of an existing disorder.  Similarly, scientists could share findings that might be relevant to diagnosis (like newly discovered biomarkers) and clinicians could share novel uses of off-label medications, therapeutic successes, and interesting case reports.

Each medication could have its own Wiki page, with complete FDA approval information and dosing.  Herbals could be included.  To be fair, pharmaceutical companies would have free access to their documents, but any changes made by industry would be flagged as such.  Users could even upload cost data to help patients find affordable generic alternatives.

But the APA needs to make an even stronger statement that we’re not just old guys sitting around smoking pipes.  We need to go balls to the wall.  We could allow users to upload videos of unique patient presentations (with the proper HIPAA safeguards in place, like black rectangles over patients’ eyes, etc), public-domain lectures by famous psychiatrists, and links to journal articles describing new and relevant findings.  We could also add references to fascinating psychiatry blogs like this one. (lol)

Patients could also upload their own experiences, in YouTube format.  Their videos would be cross-referenced to the relevant diagnoses and/or medications.  Videos with the most “hits” could win a prize.  Maybe we can link terms to their Urban Dictionary entries.

We could add clips from Hollywood movies depicting particular disease presentations.  We could add links to Amazon.com to purchase relevant books (and use the Amazon Associates revenue to help manage server costs).  We could include a Skype plug-in that would allow users to chat with other people logged on at the  same time.  We could even sell space to advertisers like Groupon (“10 sessions of psychotherapy for the price of 5 in Chicago!!”) or, for those over 21, porn sites (targeted specifically to readers of the “Paraphilias” entry).

Social media is the future, and the APA really needs to get with the program!  An animated GIF logo.  An MP3 theme playing in the background of each page.  A Flash-based interface (sorry, iPad users).  The APA could even create new, edgy slogans for itself and for the DSM.  For instance, it’s not DSM-5 anymore, it could be “D5M-ph!\/3″.  It’s not just a “living document,” it can be the most 4w3soM3 social media psychiatry destination on the planet!   OMG!!!!!!1!

Let’s do it.


The Balance of Information

May 19, 2011

How do doctors learn about the drugs they prescribe?  It’s an important question, but one without a straightforward answer.  For doctors like me—who have been in practice for more than a few years—the information we learned in medical school may have already been replaced by something new.  We find ourselves prescribing drugs we’ve never heard of before.  How do we know whether they work?  And whom do we trust to give us this information?

I started to think about this question as I wrote my recent post on Nuedexta, a new drug for the treatment of pseudobulbar affect.  I knew nothing about the drug, so I had to do some research.  One of my internet searches led me to an active discussion on a site called studentdoctor.net (SDN).  SDN is a website for medical students, residents, and other medical professionals, and it features objective discussions of interesting cases, new medications, and career issues.  There, I found a thread devoted to Nuedexta; this thread contained several posts by someone calling himself “Doogie Howser”—and he seemed to have a lot of detailed information about this brand-new drug.

Further internet sleuthing led me to a message board on Yahoo Finance for Avanir Pharmaceuticals, the company which makes Nuedexta.  In one of the threads on this board, it was suggested that the “Doogie Howser” posts were actually written by someone I’ll call “TS.”  Judging by the other posts by this person, “TS” clearly owns stock in Avanir.  While “TS” never admitted to writing the SDN posts, there was much gloating that someone had been able to post pro-Nuedexta information on a healthcare website in a manner that sounded authoritative.

Within 24 hours of posting my article, someone posted a link to my article on the same Yahoo Finance website. I received several hundred “hits” directly from that link.  Simultaneously (and ever since), I’ve received numerous comments on that article, some of which include detailed information about Nuedexta, reminiscent of the posts written by “Doogie Howser.” Others appear to be written by “satisfied patients” taking this drug.  But I’m skeptical. I don’t know whether these were actual patients or Avanir investors (or employees); the IP address of one of the pro-Nuedexta commenters was registered to a public-relations firm in Arizona. Nevertheless, I have kept the majority of the posts on the blog, except those that contained personal attacks (and yes, I received those, too).

The interesting thing is, nothing “TS”/”Doogie Howser” said about Nuedexta was factually incorrect.  And most of the posts I received were not “wrong” either (although they have been opinionated and one-sided).  But that’s precisely what concerns me. The information was convincing, even though—if my hunch is correct—the comments were written for the sake of establishing market share, not for the sake of improving patient care.

The more worrisome issue is this: access to information seems to be lopsided.  Industry analysts (and even everyday investors) can have an extremely sophisticated understanding of new drugs on the market, more sophisticated, at times, than many physicians.  And they can use this sophistication to their advantage. Some financial websites and investor publications can read like medical journals.  Apparently, money is a good motivator to obtain such information and use it convincingly.  Quality patient outcomes? Not so much.

So what about the doctor who doesn’t have this information but must decide whether to prescribe a new medication?  Well, there are a few objective, unbiased sources of information about new drugs (The Medical Letter and The Carlat Report among them).  Doctors can also ask manufacturers for the Prescribing Information (“PI”) or do their own due diligence to learn about new treatments.  But they often don’t have the time to do this, and other resources (like the internet) are far more accessible.

However, they’re more accessible for everyone.  When the balance of information about new treatments is tipped in favor of drug manufacturers, salespeople, and investors—all of whom have financial gain as their top priority—and not in favor of doctors and patients (whose lives may be at stake), an interesting “battle of wits” is bound to ensue.  When people talk a good game, and sound very much like they know what they’re talking about, their motives must always be questioned.  Unfortunately—and especially under the anonymity of the internet—those motives can sometimes be hard to determine.  In response, we clinicians must be even more critical and objective, and not necessarily believe everything we hear.


“Decision Support” in Psychiatry

January 28, 2011

I’ve long believed that, just as no two psychiatric patients are identical, there is– and never will be– a “one size fits all” approach to psychiatric care.  However, much work has been done in the last several years to develop “algorithms” to guide treatment and standardize care. At the same time, the adoption of electronic health record (EHR) systems– which are emphasized in the new U.S. health care legislation– has introduced the possibility that computerized decision-support systems will help guide practitioners to make the right choices for their patients.  It is my opinion that such approaches will not improve psychiatric care, and, in fact, will interfere with the human aspect that is the essence of good psychiatric practice.

Clinical decision support,” or CDS, is the idea that an algorithm can help a provider to give the right kind of care.  For a busy doctor, it makes sense that getting a quick reminder to prescribe aspirin to patients with coronary artery disease, or to give diet and exercise recommendations to patients at risk for obesity or diabetes, helps to ensure good care.  Several years ago, I actually helped to develop a CDS system designed to remind primary care doctors to avoid opiate painkillers (or use them with caution) in patients who had a history of substance abuse or other relative contraindications to narcotics.  At the time, I thought this was a great idea.  Why not harness the ability of a computer to gather all the data on a given patient– something that even the best doctor cannot do with absolute accuracy– and suggest the most advisable plan of action?

Now that I spend most of my time actually practicing medicine, and using two different EHR systems, I’m having second thoughts.  While I appreciate the ability to enter patient data (and my notes) into a system that is instantly accessible by any provider in my office at any time, and write prescriptions with a few clicks of my mouse, I’ve begun to resent the ways in which EHRs tell me how to practice, particularly when (a) they give recommendations that I would employ anyway (thereby wasting my time), or (b) they give recommendations that deviate from what I believe is right for the patient.

Obviously, the latter complaint is particualrly relevant in psychiatry, where each patient presents a different background of symptoms, stressors, preferences, and personal history.  When anyone asks me “who is your ideal patient for drug X?” or “what is your first choice of drug for depression?” I find it hard to give an answer.  Treatment choices come down to a feeling, a gestalt, incorporating both observable data and intuition; it’s hard to describe and impossible to quantify.

One example of a psychiatric CDS is based on the Texas Medication Algorithm Project (TMAP).  The TMAP was developed to help providers determine what medications to use in the treatment of mood disorders; the first version of TMAP for depression was designed in 1999 and implemented in a computerized CDS in 2004.  A pilot study involving four primary care providers, published in 2009, showed that depression outcomes were slightly better (i.e., scores in the HAM-D were lower) in the group using the CDS.  (This may have been due to the setting; in a busy primary care clinic, any guidance to address depression symptoms may improve outcomes relative to no guidance at all.)  However, a follow-up study by the same group found that it was much harder to implement the CDS on a more widespread scale in mental health clinics, due to technical problems, poor IT support, billing & coding problems, formulary issues, recommendations that providers disagreed with, lack of time, and impact on workflow.

That may have been for the better.  A new study in this month’s Archives of Internal Medicine by Romano and Stafford shows that CDSs may just be a waste of time and money.  They evaluated over 330 million ambulatory care patient visits using EHRs over 2005-2007, 57% of which involved at least one CDS, and found that, on 20 quality-of-care indicators, using a CDS contributed to improvements in treatment (i.e., treatment concordant with established guidelines) on only one measure.  (Two measures involved psychiatric conditions– one was for the treamtent of depression, and the other was to remind providers not to use benzodiazepines alone for depression treatment.  Neither of these measures showed improvement when a CDS was used, relative to no CDS.)

So despite all the resources devoted to electronic medical records and clinical decision support systems to improve care, the evidence seems to indicate that they don’t.  Either doctors ignore CDSs and provide “practice as usual” anyway, or the CDSs give recommendations that doctors already follow.

This may be good news for psychiatry, where treatment guidelines (thankfully) offer a great deal of latitude, but CDSs, by their very nature, may restrict our options.  In the future, then, when we believe that the patient sitting in front of us is a good candidate for Effexor, or Seroquel, or interpersonal therapy with no meds at all, we may no longer need to explain to a computer program why we’re ignoring its recommendation to try Prozac or Haldol first.

In my opinion, anything that preserves the integrity of the physician-patient interaction– and prevents the practice of medicine from turning into a checklist-and-formula-based recipe– preserves the identity of the patient, and improves the quality of care.

Addendum:  See also a related post today on 1boringoldman.com.


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