Friday, March 5, 2010

EHR's and APA

@dr_bob ( suggested psychiatrists might embrace an EHR (EMR) provided or sponsored by the Amereican Psychiatric Association. I said that might scare some of us away. He countered with the question of whether low cost might be an incentive.

I see 2 issues here. First the EHR: I learned a little Fortran in '69 at a summer job at NASA when the equivalent of pressing enter was to put a rubber band around a stack of punch cards, drive them across the base to the data reduction center, and drop them off at the IBM 360. With luck you got a printout the next day. I started patching together my own ersatz EHR around '84 after I bought my first PC. Now I use, on a Tablet PC I can hold in my lap and write upon while sitting with a patient, a combination of MS Word, GoldMine (contact management), iscribe (soon to be allscripts, online prescribing), efax, and Dragon. For evaluations and forensic reports I use Audiacity to create an mp3 which I encrypt before I ftp the file to New Delhi for transcription. I have templates for reports. I use Excel for keeping track of time and Access for record reviews on forensic cases. My billing software is still on an old DOS PC. I frequently synchronize my computer with my office manager's desktop, and her desktop with my (now obsolete) Palm Treo. I still do not trust the digital version of my records; I print a new page every time I add a progress note or paste in lab results and put it in a manila folder. I use Skype for some patient contacts. I do not "bill electronically" so I am not a covered entity under HIPAA.

I tried to "upgrade" to an EHR around 1988. I spent hours researching the product to make sure it would do everything I wanted it to. It took only about 2 days of use for me to discover that it was a total flop and revert to my existing system.

I could write pages about features, capabilities, bells and whistles, but the critical element for me that I doubt I will find in an EHR is this: My contact management software holds not only all my patient contact information, but also all my business, forensic, and personal contact information. I have everything in one place, two if you count the smart phone, practically all the time and everywhere I go. But after I mistakenly sent an email intended for a friend to the executive director of my state psychiatric association I decided I would not even keep a record of any patient's email address, much less communicate with patients via email.

So let me know when they write an EHR that allows me to keep all my non-patient contact info in the same place as my patient contacts. I also want it to be "in the cloud" and to be fully integrated with a smart phone like the iphone or Nexus One.

Now for APA: I'm disenchanted with the organization. I told Dr. Bob I probably would quit were it not for the cheap professional liability insurance, and for the opportunity to torment the risk managers there. I believe APA is stuck in the 1950's, still thinking of psychiatrists as "therapists" and of psychoanalytic theory as a core competency in psychiatry. And when I made inquiries about the professional liability insurance underwriting debacle several years ago someone in the APA administration had the audacity to refuse my questions based on a policy of not releasing that information "to the public."

So I don't want to get any more "hooked on" APA than I already am. On the other hand the idea that large numbers of practicing psychiatrists might have the same EHR appeals to me. And of course the cheaper the better.


  1. moviedoc,

    Wow, what a system!

    I bounced my APA EHR idea off other members of APA and AMIA, and the upshot is a few of us are going to propose a panel for the AMIA meeting this fall. The working title is:

    Is an EHR More Like a Pair of Pants or a Bridge: Customization vs. Standardization and the Consequences for Adoption

    My idea is that if an EHR were provided by APA, lots of psychiatrists would be willing to adapt to its limitations. It would be like a bridge; APA would build it and maintain it, and psychiatrists would go out of their way to use it.

    But not you. You have what I'd consider an extreme example of a customized system. It's like a pair of pants that fits you just right. The more psychiatrists like you there are, the slower EHR adoption by psychiatrists will be.

    Regarding patient contact info, any EHR should let you add non-patients. Just don't tell it they aren't patients!

    And regarding APA, think of this as an opportunity to torment tech support? :-)


  2. Dr. Bob: I'm glad to hear you're proposing the panel.

    There are no other psychiatrists like me. That may not be a bad thing.

    I didn't mean to imply that my patched together system is perfect. It is not.

    The exciting news is that I have been (in spite of the way I feel about APA) looking at the APA sponsored credit card processing service, Solveras. They offer a service called Smartpay (?) that not only allows you to use a "wedge" connected to your computer to swipe cards, but allows patients to pay bills through a browser. Imagine if an APA sponsored EHR could be integrated with Smartpay. I could allow patients to pay me online at the same time as a med management visit via Skype. I'm not sure it couldn't replace my entire billing system, except for printing CMS forms to submit to insurers.

    As for adding non-patients: maybe. The trick there will be to keep the apps flexible and general enough that they will accommodate differing practice styles. That's what's good about apps like Act and Goldmine. Even MS Word: I use headers to record drug start/stop dates, names of other treaters, meds I am not prescribing, AA recovery dates, and date of last hepatic function test.

    But the idea of tormenting tech support might really nail it for me.

  3. moviedoc,

    First, I didn't mean to imply that you and any psychiatrists like you are a bad thing. I just meant that you wouldn't be the "target audience" for an APA EHR. But it would still be a big step forward if lots of other psychiatrists adopted EHRs. One step at a time.

    I'm surprised you're printing out CMS forms. That's to keep from being a covered entity?

    I hadn't heard of Solveras, thanks for that info!


  4. So the target audience might not look like me, but like what then? I know that many psychiatrists still write their notes on paper by hand by virtue of having reviewed their records in the course of forensic work. It would be quite a different process taking everything digital for the first time versus upgrading one aspect of already digital records at a time. You will likely want to survey to see what everyone is doing now before designing options.

    You are correct about the CMS forms:

  5. moviedoc,

    Exactly right, going digital for the first time is taking a leap, and I think facilitating that should be a focus now. There's two parts to that: (1) inputting information digitally instead of onto paper and (2) converting information already on paper. IMO (2) is actually optional, it could just be a hybrid system until the information on paper doesn't need to be saved any longer. The lowest-common-denominator approach to (1) might be continuing to write on paper, scanning it into the system, and shredding the paper.


  6. Bob:

    You need old records to refer back to yourself, to send to other providers, and to defend yourself in a malpractice or licensure action, all of which are rare, provided you at least have the med history. I would not convert or scan, and I would keep paper. Destroying it mostly just saves a little space. You probably wouldn't need the old record in hand for more than 2 visits during the transition. I once looked at a case for the state licensing board and found records 20 or so years old that exonerated a physician. There's no statute of limitations on licensing complaints in our state.

    But I would not continue writing on paper. I swear by the tablet PC(which can sometimes read my handwriting when I can't). That should be the centerpiece of any EHR.

    Thinking over what you say again: I would discourage continuing to keep handwritten notes. If you're going to the trouble of scanning them anyway, using macros, templates and voice recognition to convert to digital text will be well worth it for legibility and search-ability.

  7. moviedoc,

    I don't think it's optimal to continue to write on paper, either. But some psychiatrists may make the leap to an EHR only if they can. Baby steps...


  8. Bob,

    That's true. More for my wishlist: I document family with a genogram. There are at least a couple apps for this. Could be integrated with an EHR.

    Integrate with (if they still have a place for patients to monitor sleep times, moods, etc.

    And just a couple days ago a patient showed my an iphone app that tracks sleep activity. The accelerometer in the phone detects movement like and actigraph if placed on a corner of the mattress.

    Might HIPAA provide for consistent coding to allow all those, and more, to talk to each other?