EMRs and Zombie Psychiatry

I consider myself to be a fairly tech-savvy guy.  I grew up in the 80s and computers have been a part of my leisure time, my academic life, and my work environment for as long as I can remember.  But using an electronic medical record (EMR) is testing my patience.

More importantly, it’s yet another example of an external influence which is changing the practice of psychiatry.  And not for the better.

I learned how to practice medicine from teachers who valued the essence of the interpersonal relationship between patient and doctor.  What attracted me to psychiatry in particular was the fact that in this field, these unspoken and unquantifiable aspects of the doctor-patient dyad are paramount, much more so than in any other medical specialty.  The patient’s subjective feelings about the therapeutic relationship—the patient’s unconscious transference of experience from past relationships into the present, for example—are as much a part of the therapeutic process as his or her verbal reports or directly measurable behavioral symptoms.  The “soul” of psychiatry lies in this nonverbal interaction.

Moreover, this relationship transcends time.  For as much as we like to bemoan the “15-minute med check” appointment, the truth is that fifteen minutes is plenty of time for an expert clinician to get an overall feeling for a patient—the “Gestalt” impression that informs the treatment process.  By the same token, a one-hour session by a poorly trained clinician is nothing more than data gathering.

EMRs are changing how we document information.  One could argue, correctly, that documentation has always been an important part of clinical care, and not directly related to the doctor-patient relationship.  However, a well-written note (not to mention the exquisitely detailed psychodynamic case formulations from years past) can convey a rich trove of information about a patient’s history, symptoms, underlying pathology, and future goals.

The type of information we document in an EMR, however, is different.  I’ve commented elsewhere that the ideal EMR for a psychiatrist would be a word processor and an encrypted hard drive.  Nothing more.  Just let me enter all the information that I think is relevant in a given session and save it for next time.

But EMRs weren’t designed for the psychiatrist or the patient.  They were designed for administrators, billing experts, lawyers, insurance companies, and others who care more about the quantifiable aspects of the interaction (the diagnosis, the medication prescribed, the presence/absence of discrete symptoms) than about the patterns of symptoms, the clinician’s subjective assessment, and the hypotheses underlying the patient’s behavior which are being actively tested in the therapeutic relationship.

The amount of time it takes me to document everything that is required for “correct billing” of my appointments (and to double-check everything, lest I get a call from my administrator the next day to “fix the chart”) takes up virtually the entire scheduled appointment time.

But my concern here is not about the time it takes, or even about the nuisance of having to click on a few dozen boxes during each patient encounter, or open six different documents—in different formats, in non-overlapping windows—to see what’s happened since a patient’s last visit.  (I like to think that I’m a quick enough learner to do all of that.)  My concern instead is with how I’m now starting to think of patients not as human beings with interesting and complicated histories which inform my care, but rather as collections of symptoms which change from visit to visit.

EMRs demand measurement and assessment of patients on scales that are, for the most part, arbitrary, and which may be completely “off the mark” vis-à-vis what’s really happening in a person’s life.  They ask us to quantify things that cannot be quantified, and distract our attention from what might be truly significant in the patient’s life at the time of the encounter.

Hey, maybe that’s okay.  After all, it’s the monthly visits by patient 2010-00224, dx code 296.34, that pay the bills.  And as long as I’ve checked the boxes next to “depressed mood” or “insomnia” or “feelings of guilt” (not to mention the other two-dozen boxes I need to check for his mental status exam and review of systems), and updated his problem list, and made sure I checked the box indicating he isn’t suicidal (never mind whether I actually asked him or not), that counts as “good” care.

But by this time, I’m not a psychiatrist.  Heck, I’m not even a human, I’m entranced, soulless, and following someone else’s commands.  A zombie.  And patient 2010-00224 deserves more than that.

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18 Responses to EMRs and Zombie Psychiatry

  1. moviedoc says:

    You should get a different EMR Steve. Mine allows all the text I can key in or dictate and doesn’t demand that I check any of those boxes.

    15′ is not always enough time, even for an experienced clinician if the patient is complicated or challenging. More on that later.

    Unconscious and transference are terms of art in psychodynamic and psychoanalytic psychotherapy. They are irrelevant to psychiatry per se, and, for example, to the family systems model of psychotherapy in which I was trained. They have no place in my psychopharm practice. They are modernist concepts that I believe have been rejected by post modern models like narrative psychotherapy.

    • stevebMD says:

      “You should get a different EMR”

      Not always possible. Especially when you’re talking about a bureaucracy in which the people purchasing the technology are not those using it.

      “15′ is not always enough time”

      Yes. but an astonishing amount of information can be gathered in a 15-minute encounter, especially by an astute clinician. My point was to show that when the clinician’s fifteen minutes are devoted to mindless pointing-and-clicking instead, it doesn’t matter how “astute” he or she is: it’s a nearly complete waste of time.

  2. moviedoc says:

    “Especially when you’re talking about a bureaucracy in which the people purchasing the technology are not those using it.”

    Don’t blame EMR’s for the flaws of a bureaucracy!

    But the EMR should serve rather than dictate.

  3. doctorz says:

    Spot on, as usual, Steve. I’ve been able to passive-aggressively maneuver around our cumbersome EMR by deleting all the fields and typing a narrative note, which fellow clinicians are more likely to read by the way. The amazing outcome of this is that after a year of doing so, no one has notified me that I’m out of lockstep with the established system. The bureaucrats aren’t even monitoring my work, though they said they would. And because my notes are now more legible, of course, and more efficiently entered into the EMR since I type faster than I write, I consider it ironically progressive. And by the way, I don’t type my notes generally until my patient session is completed. I’m sure I’ll be outed at some point, but must say am enjoying my relative freedom for the moment and looking forward to another loophole around the gestapo when that time arrives.

  4. Neuroskeptic says:

    If you think this is bad, what about CCBT – psychotherapy without the therapist.

    doctorz’s plan sounds quite sensible. Bureaucracies often have stupid rules which they are too inept to enforce. Worth a shot.

  5. Great post. It sounds like the bureaucracy and “technology” in general have put you clinicians in an increasingly untenable position (who’s do you truly serve, the technology or the patient?).

    However, at the risk of being nit-picky, I must object to this phrase: “the doctor-patient dyad.”

    I recently used the term “dyad” myself, as in “the mother-baby dyad.” In that context, it has a very specific and STRONG meaning – the two literally function as one (for quite some time… even after the umbilical cord is cut). What affects the mother has a profound effect on the baby, and vice versa. Again, this is true in utero and out… the literature constantly refers to the “mother-baby breastfeeding dyad,” for example.

    The phrase is most commonly invoked by advocates of “attachment parenting,” “kangaroo care” and “skin-to-skin contact” – essentially those who object to the separation of baby and mother, which is so common in hospital births (and in our society in general… re: mothers going back to work at 6 weeks or less!). Separating mother and baby cause stress and distress, and hinder the natural physiological development of the baby (to many distress hormones and neurotransmitters in the brain have a DEFINITE effect on brain development). So “mother-baby dyad” is a useful term that emphasizes the inevitable, biological nature of this relationship so necessary for the survival of both.

    Turn this around to the phrase “doctor-patient dyad”… if the patient is depending on the doctor for his very survival, if the two are functioning as though an umbilical cord connects them; well… that’s just not healthy. And it’s also co-opting a phrase that normally describes a natural, healthy attachment to describe a relationship that is not a biological necessity and may sometimes not even be healthy (if, for example, the doctor does NOT have the patient’s best interests at heart and is still digesting his free lunch from the Pfizer rep).

    • stevebMD says:

      alt,

      Regarding “dyad,” yes, perhaps the nits are being picked. 🙂 But it’s always good to reevaluate the thoughts behind our words.

      I wouldn’t even begin to assume that the doctor-patient relationship resembles the bond between mother and child. That said, it is (or should be) an interdependent, “life-affirming” relationship that should be valued. In some cases, it is even a “biological necessity”– although in psychiatry that is less likely to be the case. The point of my post was to show that the therapeutic relationship is a special one, which EMRs (and, yes, Pfizer reps) tend to undermine.

      But then again, EMRs and pharma are the business of medicine, and as you write in your post, if we can’t attach a price tag to a relationship, it just doesn’t seem to have any value whatsoever.

  6. BobbyG says:

    I thought you were a cash-only concierge provider. Why should you even care about HIT? Particularly since your pieces of the SOAPe note would seem to be way low on the “O” side of things, i.e., you note your subjective deliberative (case narrative) findings, make an Assessment, proffer a Plan…

    To what extent do even you do FH, SH, PMH, Vitals, HPI, ROS?

    “Moreover, this relationship transcends time…EMRs demand measurement and assessment of patients on scales that are, for the most part, arbitrary, and which may be completely “off the mark” vis-à-vis what’s really happening in a person’s life.”

    Perhaps this is in fact the case in your specialty, but, generally in medicine, this is on old complaint — “We’re Different.”

    For the record: If I ruled the world, all doctors would be paid more like lawyers (and, yeah, I know, we all hate lawyers). I am no fan of the predominant reimbursement paradigm.

    I’m just asking here. To what extent are you feeling pressure to “conform”?

    • stevebMD says:

      Bobby: I should clarify, I’m “cash-only” in one of my practice settings, although I do work in a community mental health center part-time, and it’s the CMHC setting where my comments are most applicable.

      BTW the EMRs I use are Practice Fusion and Patient Chart Manager (PCM) by Prime Clinical, respectively. Both have their “quirks,” but PCM is loaded with bugs and other usability issues that I won’t detail here. Incidentally, I will point out that PF is free while PCM costs our clinic tens of thousands of dollars per year (and we had to hire a full-time IT staffer to deal with the bugs and the customization), so go figure.

      Anyway, the pressures to “conform” (and indeed, many of the complaints in my original post) are not platform-specific but have to do with what our payers require. Our county MH organization (which is the source of >60% of our revenue) demands specific items to be documented in each note. One could argue that these are excessive, but their thinking seems to be that if the EMR can store this information, then it should.

      Note that the long list of specifics they now require were not required just two years ago, when we were all-paper. So this is a clear example of EMRs (or their “potential”) dictating how we provide care, not patients’ interests. In other words, the EMR is one big hammer, so now all our patients have become nails.

      In the end, this mentality hurts psychiatry, which is all about the relationship between doctor and patient– something that simply cannot be measured, quantified, or documented in any EMR.

      • moviedoc says:

        Steve, if psychiatry is “all about the relationship between doctor and patient,” it’s in big trouble. This myth reinforces the stigma. Psychiatry should be about treating people who suffer from mental disorders, something we’d better be able to measure if we expect anyone to pay for it.

        Practice Fusion is not free. It’s paid for by ads for, among others, those “powerful” evil pharma people you love to hate so they can “influence” us to buy their overpriced unnecessary pro-, and other, drugs.

        One reason documentation of all those specifics wasn’t required 2 years ago is that there was no way it could be collected cost effectively.

        Having said all that I agree it seems like the money could be put to better use in your CMHC. If you really don’t like it, get out, vote with your feet. They can only operate when they have people like us to do the dirty work. If you stay, you enable them.

      • stevebMD says:

        moviedoc, I agree that we [psychiatrists] have to prove somehow that our services are valuable if we expect anyone to pay for them, but I don’t know if “measurement” (by what, checklists??) is the way to do this. We need to figure this out.

        I know PF is supported by advertising. And BTW if you haven’t been able to read between the lines of my posts, I don’t “hate” pharma, I just think we [psychiatrists] need to be more critical of what they tell us. You know, caveat emptor and all that. (Case in point: I actually want to learn more about Horizant, as a QD or BID gabapentin– if that’s what it is– might be quite useful.)

      • BobbyG says:

        Thanks.

        Practice Fusion? OMG. 😦

        For the record: notwithstanding that I work for one of the RECs, I am no unreflective Polyanna cheerleader for HIT.

        “their thinking seems to be that if the EMR can store this information, then it should.”

        I am sympathetic to this complaint. “Feature fetish.”

        “what our payers require”

        Well, that’s the crux.

  7. moviedoc says:

    “I don’t “hate” pharma”

    Coulda fooled me, but I got you to say it out loud.

    Thing is, those EHR checklists at least allow for data collection in the real clinical world. May not be any more valid than the data pharma throw at FDA, but it may allow us to be more critical. How else are you going to decide whether Horizant offers any advantage except by letting your patients try it?

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  12. PFUser says:

    All very interesting. I use PF and find it very annoying. I do not use the templates and checklists, but there is still a ton of clicking just to get from here to there and write something. I wish someone would create a “sheep or mutton” program so one could review either the narrative (sheep) or the details (mutton)

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