Several Concerns Keep Psychiatrists Wary of Electronic Records
Abstract
The heat is on.
In fact, it has been for a while—to get psychiatrists and other physicians to use electronic medical records as a way to improve efficiency, reduce costs, and boost the quality of care.
The pressure is coming mostly from the federal government through various initiatives. For example, “The American Recovery and Reinvestment Act of 2009 … [has set aside] billions of dollars … for incentives to physicians and hospitals for electronic health record adoption,” Robert Plovnick, M.D., director of APA's Department of Quality Improvement and Psychiatric Services (QIPS), pointed out in a commentary that will appear in the May American Journal of Psychiatry. “Starting in 2011, physicians who treat Medicare or Medicaid patients will be eligible for incentives of up to $44,000 over five years if they can demonstrate ‘meaningful use’ of electronic health records....”
At the same time, nongovernment entities are trying to help physicians transition from paper medical records to electronic ones. For example, the Certification Commission for Healthcare Information Technology (CCHIT) is developing standards for electronic medical records. APA's Committee on Electronic Health Records as well as QIPS are helping psychiatrists make the switch from paper to electronic records.
As a result of these efforts, “there is a bit of a land rush … with many doctors getting serious about implementing electronic health records,” Edward Pontius, M.D., told Psychiatric News. He is medical director of Access, an Assertive Community Treatment team in Portland, Maine, and a member of APA's Committee on Electronic Health Records. He has also been helping CCHIT develop electronic medical record standards suitable for psychiatrists.
But how many physicians have already taken the plunge? Only 12 percent, according to a 2008 Congressional Budget Office report (Psychiatric News, September 18, 2009). And how many are psychiatrists? “Less than 10 percent and possibly less than 5 percent,” Pontius speculated. “It's mostly people who work in large health care systems such as the Veterans Administration or Kaiser Permanente,” Plovnick ventured, noting that “there are no reliable statistics on this.”
So what does this small cadre of psychiatrists already using electronic medical records have to say about them? Both positive and negative things, it turns out.
Records You Can Read
“Paper records are horrible as far as legibility is concerned,” John Boronow, M.D., medical director of adult services and physician liaison for information services at Sheppard Pratt Hospital in Towson, Md., attested. “But with electronic medical records, everything is legible. You cannot believe how transformative that simple thing is by itself.” He and others at Sheppard Pratt have been using electronic medical records for about three years.
Moreover, electronic medical records give you “access to information across time and space,” Boronow noted. “You don't have to physically go to the basement or somewhere else to find patients' records. You can access them right from your computer, and not just from your office, but from your home or from any Internet access in the world, for that matter.”
Janis Petzel, M.D., a geriatric psychiatrist at the Veterans Administration in Augusta, Maine, concurred: “In recent years the Veterans Administration has upgraded its network capabilities so that I can get medical records from anywhere in the country without much trouble at all.”
Electronic medical records also make it easy to delve into patients' histories, remarked Lane Cook, M.D., a Knoxville, Tenn., psychiatrist who works in a single-specialty group and who uses such records. For instance, if he wants to learn quickly which medications a patient with treatment-resistant depression has already tried, Cook can easily scan the patient's electronic medical record to find out.
The electronic medical records that Cook and his colleagues use also list patients' pharmacies and their pharmacies' phone and fax numbers. “So if a patient calls me and asks for a prescription, it takes about a minute to access his or her electronic medical record, print a prescription, sign it, and fax it off to the pharmacy. It's real efficient.”
And by providing a more efficient record system than paper charts, “electronic medical records have helped us keep our staff costs down,” reported psychiatrist Chris Bojrab, M.D., president of Indiana Health Group in Carmel, Ind. “We are a practice of about 30 mental health clinicians and have around 55,000 outpatient visits a year.”
Still another plus of electronic medical records, Bojrab said, is that they have “ended the debacle of the missing or lost chart. That has been wonderful. We simply scan everything we receive into the system, and filing is done electronically.”
But couldn't electronic medical records get lost in cyberspace? Not in their case, Bojrab replied. “All we have are computers connected to the Internet.... We don't maintain servers or hardware on which our data reside. Our data are housed in a sort of high-level server farm, where it is redundantly backed up. It is basically the same kind of system that the banking industry or airline industry uses to maintain its records.”
Security Fears Overblown?
Security is one issue that arises repeatedly when electronic records are discussed.
“Secure medical records have always been a concern for psychiatrists,” Bojrab agreed. “But quite honestly, with the technology that exists today, I would argue that our [electronic medical] record system is more secure than paper records in a physician's office, where charts may be lying around.”
Confidentiality of electronic medical records has not been a problem at Sheppard Pratt, Boronow said, “but it is a lot easier to control confidentiality in a standalone mental health setting like Sheppard Pratt than in a big medical-surgical environment where the risk of violation of privacy is much greater.”
And patients' concerns about the limits of privacy protections, for example, access by insurance companies and other entities to confidential health information under federal regulations, can deter patients from sharing sensitive health information with their physicians, Deborah Peel, M.D., an Austin Tex., psychiatrist says. “When patients realize they can't control who sees their electronic health records, they will be far less likely to tell their doctors about drinking problems, feelings of depression, sexual problems, or exposure to sexually transmitted diseases,” she wrote in an opinion piece in the March 23 Wall Street Journal.
Another potential downside of electronic medical records, Boronow pointed out, is the risk of propagating incorrect information, and it can occur through a couple of mechanisms. “The most common is the ‘cut and paste’ or ‘copy forward’ mistake where you bring patient information from several years ago forward and don't bother to update it.”
The accuracy of information in patients' electronic medical records can also be jeopardized when more than one clinician is allowed to enter information into them, Petzel remarked. In a hospital in which she once worked, primary care doctors, nurses, and other clinicians placed information in electronic medical records that she was maintaining. As a result, she didn't know which clinician had entered which information and whether it was accurate.
Good Typing Is Essential
“You really need to be able to type 45 words a minute or better to make electronic medical records efficient,” Cook stressed. Also, “patient acceptance is good if you can type fast and listen to a patient while typing. But if you type slowly and have to look at your keys, patients can get frustrated because of your difficulties.”
Actually, “I think it's rude to sit and type on a computer when you're talking to a patient,” Petzel said. “I still have trouble in my VA clinic turning and making myself type on a computer while talking to someone.”
Petzel dislikes electronic medical records for another reason: “You check lists, you do templates, you cut and paste. As a result, you end up with a lot of verbiage in the record, but not a lot of information. In other words, the story of what has been going on with a patient is very difficult to discern from an electronic medical record unless somebody takes the time to sit down and type an old-fashioned note, which is kind of disappearing.”
Yet another vexing aspect of many electronic medical record systems is that they are often not connected to each other, said Cook. “For instance, if I send a patient to the hospital, I can't connect my program to theirs and exchange information.”
Finally, a disadvantage of electronic medical records in psychiatric inpatient settings is that “all the software that has been developed is targeted to medicine and surgery,” Boronow said. “This means that if you're in psychiatry, you have to build all those mental status exams and notes … by hand.”
In the psychiatric outpatient setting, though, “there are a number of excellent electronic medical record systems that are good to go,” Boronow reported. So should psychiatrists take the plunge and invest in one of them?
Bojrab said “yes.”
So did Cook, although he added, “I do think the search for software can be difficult, and the software can be expensive.”
Petzel, in contrast, opined, “For a small practice to have an electronic medical record is essentially pointless as far as I can see unless you are part of a larger network.”
So what is the future of electronic medical records in psychiatric practice?
Thanks to government and insurance-company pressure, as well as patient expectations, “I think they are going to become a standard of care,” Bojrab said.
Peer pressure will also nudge psychiatrists into the electronic medical record world, Cook predicted, to the point that “patient charts will become obsolete.”
Plovnick, however, is not so sure. “If electronic health records are found to be more burdensome than useful, if they do not adequately protect patient privacy, and if incentive programs to get physicians to use them fizzle, then their adoption rates are unlikely to increase considerably. On the other hand, there is currently a lot of activity to create electronic health record interoperability. Increased demand for electronic health records could lead to a more diverse selection of products and decreased cost. As a result, their adoption by psychiatrists and other physicians might rise rapidly.” 
