by Carol E. Watkins, M.D., and Glenn Brynes, M.D.
[Winter 1997; Vol. 24 No. 4]
In the fall 1997 Maryland Psychiatrist, we discussed the basics of buying and setting up a computer system. In this article, we will expand on those topics and discuss how you can actually use your computer in a psychiatric practice.
Computers are becoming an important and even necessary part of our culture and our profession. As with any new technology or major cultural change, their arrival has lead to a range of strong emotions. Some people fear computers will destroy cherished aspects of their world. Like Ned Ludd, who sabotaged steam powered machines during the British industrial revolution, they see computers as a kind of evil that is best eliminated. At the other extreme are those who idealize computers as wonderful, compliant servants that could eliminate drudgery if we place our trust in them. Most of us have opinions between these two extremes.
In our own lifetimes, we have seen an explosion in the power and the pervasiveness of computing. About 25 years ago, as a high school student, Dr. Watkins brought a calculator to a math class and caused the school to write a whole new set of rules about when one could use such a device. Only a few years later, her college required each freshman to own a calculator. Now, some colleges expect students to bring their own computers. Moore’s Law predicts that the information processing rate of computers will double every 18 months. This rule of thumb has actually held true for the past 15 years.
Although this explosion in technology may seem daunting, the new, more powerful computers are actually much easier to use than their predecessors. Most of us can remember ruining a program by making a single typographical error. Now major software developers, such as Microsoft, test their programs with people with a variety of ability levels and cognitive styles. Some programs even warn the user when he is about to do something to make the system crash. Programs often come both with an on-line help screen and, for those uncomfortable with help screens, a printed manual.
Among the variety of practice management programs, some cover billing and managed care; a few integrate both the clinical and the accounting. Some practice management software programs can streamline your office practice. For example, programs that track managed care reviews will alert you when a care plan is due. You then call up the most recent care plan, type in the necessary changes, and fax it to the managed care reviewers. The American Psychiatric Association has published a pamphlet containing information about a number of practice management programs*, but we have not yet found an all-inclusive program that we like.
When evaluating practice management programs, talk to people who have used them before. Talk to an office manager for a reliable appraisal of a program’s accounting and billing sections. One psychologist told us that he liked a particular program; however when we spoke to his office manager, she told us that the program was very inefficient and had caused them to have to hire extra office staff.
You can integrate scheduling software (computer organizers) with the patient records. The powerful search functions can call up an appointment by searching for one of its attributes. Using “Outlook,” “Ascend” or other scheduling software, you can integrate the schedules of an entire group and find times that everyone is free for meetings.
A wide variety of programs for use within the clinical setting range from computerized scoring of rating scales to computer-guided clinical interviews. Serial use of rating scales can help monitor a patient’s response to medication changes. The psychiatrist or a nonphysician in the same practice can administer these. Several programs will alert the physician to potential drug interactions. A patient’s parent can fill out programs such as the Devereux Scales of Mental Development in advance. The program will norm the results by age and will suggest diagnoses and areas for further questioning. Some clinicians may use computer guided clinical interviews that resemble a decision-tree. Others may find this approach intrusive and artificial.
If a physician is sharing treatment with a social worker in the same practice, he/she can have immediate access to therapy notes and use this information to help supervise treatment and manage medications. Finally, the use of a word processor can end the problem of illegible handwriting. (Unless you are using handwriting as a form of encryption.)
The past year has seen a proliferation of on-line CME in psychiatry and other specialties. This offers an inexpensive and convenient way of expanding knowledge and getting the required hours of continuing medical education.
Many parents and educators are aware of the large variety of educational software for children. These may play a larger role in the education of children with learning disabilities. For example, software with immediate visual and auditory feedback might motivate a child with attention deficit/ hyperactivity disorder. A child with dysgraphia (spelling and writing difficulties) might enjoy haunting a house in a children’s keyboarding program or outwitting the “Master of Mischief” while playing a computer spelling program.
Many individuals will never need a large, complex system. Some practices keep their clinical notes on paper and only computerize their billing. Some solo practitioners keep their clinical notes on a laptop, but do not computerize their billing or scheduling. These two approaches require only a single computer and do not require transmission of data over the phone lines. They cost less and present less complex security problems. Mid-sized practices may decide to link several computers together into a LAN (local area network). This permits data sharing. It also achieves economy of scale by permitting the sharing of resources, such as a large central computer (the server) or high-speed printer. Nationwide mental health organizations may link hundreds of computers together into a WAN (wide area network). The set up and maintenance of these systems is more complex, but the actual use of a well-managed network is fairly easy.
Computer records can be made more secure. Paper records can be locked up, but are usually not encrypted. Several levels of security can protect electronic records from unauthorized use; however, they work only if humans remember to use them consistently. Security is especially important if you plan to transmit information between computers. Even if you never plan to use a computer in your own practice, you should be able to evaluate security protocols of organizations that might receive your patients’ records.
If your office burned down, you might lose all of your medical and billing records. However, if you stored your records on tape or disks, you could save copies in multiple locations. You can then have access to the information when you are at home. This can also be useful if you are called at night by an emergency room or by a patient who wants a medication refill.
We have seen the aphorism posted several times on the Internet, “Computers save time like kudzu prevents soil erosion.” They can save time, but you have to be careful not to get drawn into the lure of switching prematurely to new software or excessive equipment upgrades. Computer software or on-line counseling are not a substitute for human contact in psychotherapy nor in education.
In future articles, we will deal with practice management software in more detail. We have received requests for more information about computer security, an issue whose complexity may be beyond the scope of a brief article. The MPS Computer Committee is planning a symposium in the spring. We hope to use that time to deal with these and other issues in more depth. If you have feedback for the committee, please contact us by phone at 410-329-2028 or by E-mail at ncpa@qis.net.
* Practice Management Software, April 1997; American Psychiatric Association Office of Economic Affairs and Practice Management (202-682-6212)
Drs. Watkins and Brynes, a wife and husband team in private practice in nothern Baltimore County, are co-chairs of the Computers in Psychiatry Committee of the Maryland Psychiatric Society.