In today’s practice of medicine, it is highly unlikely that any physician entering into or already in practice will remain in the analog age without some type of health information technology. Computers today are just as important to the psychiatric office as was the proverbial couch, and they play a central role in data collection, storage, and retrieval in various domains such as scheduling, billing, and record keeping. For the novice or even for the experienced purveyor of electronic goods, to evaluate the numerous technologies available for their relevance to digital practice can be rather daunting. This article serves as a guide to the practicing psychiatrist to determine what technologies will be most useful—if not mission-critical.
Electronic health records
One of the first challenges is to determine what electronic health record (EHR) product to purchase as a foundation for a psychiatric practice. At the 2009 American Psychiatric Association (APA) annual meeting, more than a dozen vendors contended that their product is the best and most adaptable to the needs of every psychiatrist. There are some guiding principles to consider when choosing from this smorgasbord of vendors.
To begin with, it is important that any EHR product examined for consideration be approved by the Certification Commission for Health Information Technology (CCHIT).1 While this certification is not a guarantee that the product will serve every need, it does indicate that the EHR system will enable providers to meet all meaningful use objectives. Products must significantly exceed minimum federal standards requirements—such as those specified in the Health Insurance Portability and Accountability Act—and must have proved usability at multiple sites.
Another key issue to consider is whether the EHR vendor has been in business for an extended period. Many EHR products have been created by physicians who were frustrated with existing products; the longevity and success of these products can be measured in terms of years in business as well as number of current and satisfied customers.
All too many new EHR vendors come out every year and just as many vendors cease operations. One key feature of CCHIT certification is an interoperability standard, which means that practice data can be migrated from one vendor to another as needed.
Once you have determined that the EHR system you are considering has CCHIT certification, it is time to consider how your practice will run. This will dictate the priorities of certain features. For example, if the practice is located at multiple sites, then a Web-based EHR system makes the most sense—especially if the practice has multiple users that include physicians and staff. A few Web-based EHR systems, such as LifeRecord2 and eClinicalWorks,3 also provide remote access via smartphones, such as the iPhone and BlackBerry. This remote access is vital if the practitioner is often out of the office and needs to be able to remotely access patient records, check laboratory results, review messages, check schedules, enter charge capture, and refill prescriptions.
Although selecting an EHR system seems daunting, once you have screened a few of the systems using the parameters described above, the choice becomes a function of the results of a “test drive.” It is helpful to read reviews of EHRs found on the APA’s Web site “Members Corner,”4 but more important will be the intuitive nature of how the system is set up during the test drive. In general, if the system doesn’t work well “out of the box” and requires extensive training, it is not a system to consider.
■ It is important that any electronic health record product examined for consideration be approved by the Certification Commission for Health Information Technology.
■ The smartphone is one of the more critical tools in psychiatric practice. Among the popular applications is access to drug reference guides that provide dosing information, a drug-drug interaction checker, formulary information, a list of common adverse effects, black box warnings, contraindications, pill pictures, and safety and monitoring information.
■ The National ePrescribing Patient Safety Initiative provides a free Web-based system for every physician in the United States.
■ Information backup is crucial and the backup frequency is based on the number of days the practice can afford downtime to restore the system. In addition to on-site backup, off-site backup is highly recommended.
Over the years, the personal digital assistant (PDA) has given way to the smartphone, which is essentially a PDA with data access to the Internet. This piece of hardware is one of the more critical tools in the psychiatric practice. It provides remote access to an EHR system, but it also does much more. This field was defined and dominated by the Palm operating system, which was surpassed by Windows Mobile and subsequently by the iPhone and BlackBerry. Although the Google Android is new to the scene, it is quickly becoming a device to consider because many developers are creating applications for it.
One of the most popular applications on the smartphone for physicians is for accessing drug reference guides, such as Epocrates.5 These guides provide dosing information, a drug-drug interaction checker, formulary information, common adverse effects, black box warnings, contraindications, pill pictures, safety and monitoring advice, and much more information at the point of care.
Lexi-Drugs6 is another popular handheld drug reference guide, which is known for having additional information, such as Canadian and international brand names, as well as pharmacokinetic and pharmacodynamic information. The Tarascon Pharmacopoeia,7 which many physicians used in medical school, is now available on the handheld platform. Many of these drug references provide a medical calculator to facilitate, for example, determination of body mass index, corrected QT interval, and absolute neutrophil count. However, numerous publishers also have created stand-alone medical calculators, such as Mediquations,8 for the iPhone and Android.
Medical references (eg, practice guidelines and textbooks) are readily available on multiple smartphones. If Internet access is available, either via WiFi or the cellular data network, users can access PsychiatryOnline.com9 on their device via the Web browser. PsychiatryOnline provides access to DSM-IV, APA practice guidelines, and numerous psychiatric textbooks and journals, as well as handouts for patients and their families. Access on the go is possible because the site detects the mobile browser and adjusts the graphics and layout to make it accessible for the smaller screen of the smartphone.
If access to wireless networks is a problem at times, then having medical references installed on the smartphone is a highly recommended strategy. Skyscape,10 an extremely popular medical information provider, licenses many popular titles from various publishers, including American Psychiatric Publishing Inc, Oxford University Press, and Lippincott Williams & Wilkins. This medical information platform distills texts into readable chunks, with excellent navigation and hyperlinks between different references. These titles are available on a subscription basis and can be viewed on practically all platforms, including the new Android and Palm Pre. If a particular title is not available on the Skyscape platform, it may be available at Unbound Medicine11 or Handango.12
Although there are numerous online sites for continuing medical education (CME) credits, many physicians overlook the smartphone as a mechanism to earn CME credits. Its obvious advantage is portability: CME tests can easily be completed, whether at the beach or at the airport. ReachMD13 provides medical news programs on Sirius-XM satellite radio and offers podcast downloading onto an MP3 player. It also produces CME audio vignettes in various 0.25 CME credit increments, with questions to be answered on the device. Epocrates also has mobile CME bundled with its drug reference product, and Medscape14 has created more traditional text-based CME with follow-up questions for the iPhone and BlackBerry smartphones.
One of the key features of the smartphone is its ability to browse the Internet for medical content available on many Web sites, such as PubMed.gov.15
Not all mobile Web browsers are created equal, however. The Apple iPhone and Palm Pre have excellent Web browsers that are quick with multitouch navigation; in comparison, the BlackBerry browser is slower and requires use of menu buttons to zoom. The one feature that sets the Palm Pre above its smartphone competitors is that its browser does have an Adobe Flash Player, which enables this device to access more Web pages with multimedia content. For example, the National ePrescribing Patient Safety Initiative Web site16 is compatible with the Apple iPhone Safari browser and Windows Mobile Internet Explorer mobile, but not with the BlackBerry browser or Palm OS browser. The one feature that sets the Palm Pre above its smartphone competitors is that the Palm Pre browser does have an Adobe Flash Player that enables this device to access more Web pages with multimedia content.
Although many EHR systems provide e-prescribing on both the computer and the smartphone, the National ePrescribing Patient Safety Initiative provides a free Web-based system for every physician in the United States. Many vendors including Microsoft, Google, Yahoo, Aetna, Dell, WellPoint, and Sprint have provided funding, while Allscripts and Surescripts provide the technology infrastructure. The goal is to reduce medication errors typically associated with paper-based prescriptions, such as transcription errors.
Once a doctor’s account is set up, patient information is entered into the system either manually or via a spreadsheet generated from practice management or billing systems. Information includes demographic details and the patient’s retail and/or mail-order pharmacies. After the patient’s information is input, the medication is selected with the appropriate instructions for its use. The system automatically checks the dosage and potential drug-drug interactions and also flags duplicate prescriptions. Once the prescription(s) is reviewed, it is sent electronically via the Internet to the pharmacy fax line. The system is able to manage restricted medications with purchase of the appropriate security prescribing paper for the state.
Key features of this system are that it provides formulary status as well as formulary alternatives and that it describes the patient’s coverage and copay. Reports can also be generated to determine the patient’s medication history. The physician’s prescribing habits can also be reviewed for practice-based learning and self-assessment, which is required to maintain American Board of Psychiatry and Neurology certification.17
The bottom line is that there is no excuse for not using e-prescribing if there is a computer in the office.
Backup and security
It goes without saying that the information stored on the computer and smartphone is more valuable than the one-time purchase cost of these devices. Information backup is mission-critical for the psychiatric practice, and the backup frequency is based on the number of days the practice can afford downtime to restore the systems. If zero days of downtime can be afforded, then a redundant array of independent disks (RAID) is necessary.18 By setting up RAID level 1, the information written on a hard drive will always be copied to the secondary drive in a process called mirroring.
In addition to on-site backup, off-site backup is highly recommended. This can be set up either with a portable hard drive that is carried home every day or via an online data storage system. The Western Digital “My Passport Elite”19 is an example of a portable backup system with automatic, continuous backup, password protection, and 256-bit hardware-based encryption. Mozy20 and Dropbox21 are examples of online backup systems that provide excellent security with encryption of files via secure socket layer over the Internet as well as encryption on the company servers. Backups can be automatic or scheduled and can be set to backup only new or changed files.
This article has described a few of the mission-critical health information tools for psychiatric practice. Many practices will use some or perhaps only 1 of the above-mentioned devices or Web sites. It is frustrating for the practicing psychiatrist that many of these technologies change every year, with improvements in speed, data capacity, or even newer features. To help weather this ever-changing landscape, it helps to maintain the attitude that technology changes or upgrades only make sense when the new features or capabilities save time or simplify the workflow process.
It is perhaps without question that today’s psychiatric practice has “gone digital,” leaving the analog for now to the patient-physician interaction in the office.
Dr Luo is associate clinical professor in the department of psychiatry of the UCLA Semel Institute for Neuroscience and Human Behavior in Los Angeles. He reports no conflicts of interest concerning the subject matter of this article.
1. Certification Commission for Health Information Technology. http://www.cchit.org. Accessed December 14, 2009.
2. LifeRecord. http://www.liferecord.com. Accessed December 14, 2009.
3. eClinicalWorks. http://www.eclinicalworks.com. Accessed December 14, 2009.
4. American Psychiatric Association reviews of electronic health records. http://www.psych.org/MainMenu/PsychiatricPractice/QualityImprovement/ElectronicHealthRecords.aspx. Accessed December 14, 2009.
5. Epocrates. http://www.epocrates.com. Accessed December 14, 2009.
6. Lexi-Drugs. http://webstore.lexi.com/Store/Individual-Databases/Lexi-Drugs. Accessed December 14, 2009.
7. Tarascon Pharmacopoeia. http://www.tarascon.com/pharmacopoeia.aspx. Accessed December 14, 2009.
8. Mediquations. http://www.mediquations.com. Accessed December 14, 2009.
9. PsychiatryOnline. http://www.psychiatryonline.com. Accessed December 14, 2009.
10. Skyscape. http://www.skyscape.com. Accessed December 14, 2009.
11. Unbound Medicine. http://www.unboundmedicine.com. Accessed December 14, 2009.
12. Handango. http://www.handango.com. Accessed December 14, 2009.
13. ReachMD. http://www.reachmd.com. Accessed December 14, 2009.
14. Medscape for iPhone. http://www.medscape.com/public/iphone. Accessed December 14, 2009.
15. PubMed.gov. http://www.pubmed.gov. Accessed December 14, 2009.
16. National ePrescribing Patient Safety Initiative. http://www.nationalerx.com. Accessed December 14, 2009.
17. Maintenance of Certification for Psychiatry. http://www.abpn.com/moc_psychiatry.htm. Accessed December 14, 2009.
18. Tutorial: how to setup a RAID array. http://www.pctechguide.com/tutorials/RAID.htm. Accessed December 14, 2009.
19. My Passport Elite. http://www.wdc.com/en/products/products.asp?driveid=740. Accessed December 14, 2009.
20. Mozy. http://www.mozy.com. Accessed December 14, 2009.
21. Dropbox. http://www.getdropbox.com. Accessed December 14, 2009.