The Patient Protection and Affordable Care Act of 2010 has expanded the market for insurance by 50 million patients. The goal is lofty and just, but if the cost pains you, you can take it to Congress or to court and dispute it. Private insurance companies will have the honor, the challenge, and the bonanza of treating the newly insured. Doctors scheduled into briefer, more time-efficient slots will have fewer minutes to talk with patients and consultants. Corporations of all kinds (eg, insurance, hospitals, software companies) are hoping to make a killing. We hope the killing won’t be the death of respectable medicine—and of our quaint, old, low-tech specialty, psychiatry.
How will the doctors keep up? The stimulus package has promised $27 billion to hospitals and clinics that use electronic health records (EHRs). The hope is that doctors will flash brilliant notes to each other, and all will be instantly available online.
The breach of privacy is one risk that may be managed with refined methods (see http://patientprivacyrights.org and also the article that appears on page 26 of this issue), but the larger problem is that software companies and attorneys have designed EHRs to be mainly behavioral, with very little personal in them. And the personal, of course, is the essence of psychiatry. The EHR forms require the following details: behavior, symptoms, goals, diagnoses, lab tests, medications, and procedural code. “Time punched in” and “time punched out” are precise numbers; noting the doctor responsible is necessary in case of lawsuits. These facts are easily specified and adequate in the hard-science specialties (diabetes, renal medicine, etc), but they leave out something vital in the softer fields, such as family medicine and psychiatry.
As psychiatrists, we are immediately immersed in emotion when a familiar patient comes into our office. When the face of the woman sitting across from us begins to quiver, our job is to keep our mouth shut for the right number of beats.
Take the case of a hypothetical long-time patient: when she says that her beloved Scottie of 15 years has died, we know just how big a loss this is. When her cheeks tremble and she says, “Buster walked into the kitchen and tumbled over sideways,” the tears pour out, she sobs, and we are stunned too. Our eyes water up a bit. Then we pull back into clinical mode. Her glance takes it all in—both our emotion, then our clinical detachment—all of which is fine . . . it’s just the way it should be in a personal relationship. It only takes a few seconds, in real time, brain time, but we think it needs to be included as a part of the encounter.
Will the efficient EHR boil the procedure down to this: “45 yrs old; major depressive disorder (296.23); vegetative symptoms; fasting blood sugar, 130; fluoxetine(Drug information on fluoxetine), 40 mg; loss of pet; 10:00 -10:20 am”? Is that it? No room is left for the person’s past, the story, the drama, or any emotion. The patient looks like a skeleton. She fits well in the EHR.
You might say that such notes are simply the outline, and that you and other doctors will know the whole story. Maybe so . . . or will EHRs train us to forget? Perhaps some of our colleagues already have forgotten. We have seen EHR reports on patients who were in a psychiatric hospital for 3 weeks; the reports showed lots of lab data, no narrative, and little suggestion of what happened during those 3 weeks. The records do (of course) name the next responsible professional—to protect against liability. Binary code takes over the brain.
The danger of the EHR is that doctors and others may mistake this stripped down abstraction for a real picture of the individual, and the personal history will be lost. A patient at a point of crisis will notice and hate the robotic treatment too—especially if the doctor’s head is down and he or she is typing during the whole visit. The doctor-patient connection will be lost. (One survey showed that 80% of hospital patients didn’t know the name of their primary doctor!)
Digital technology is a valuable tool, but if it dazzles us with its speed and control, there is the risk that we may forget the old way of connecting. People can be trained, grooved, to imitate a computer and attempt to do broadband multitasking all day. But the old social connection by faces and brains may be lost.
Effective psychiatry includes psychotherapy to some extent, even if the doses are small. Good psychotherapy is as subtle as a surgeon’s knife, needing the touch of a Yo-Yo Ma. DSM-IV (and probably DSM-5 too) and CPT codes are as subtle as cattle chutes. EHRs are the digital equivalent of cattle chutes; they work well for patients with medical illness, but they lack the subtlety of a surgeon’s knife for psychiatric patients.
Drs William Houghton and Mary Alice Houghton, married, in their early 70s, practice general psychiatry in Milwaukee and attempt to coordinate care in the marketplace of private practice (see http://www.firsttherapycoop.com).