6th Annual Meeting
Psychiatric Society for Informatics

Information Technology in Psychiatric Care: A Focus on New Clinical and Educational Applications

Saturday, May 5, 2001
Room 270, Ernest N. Morial Convention Center
New Orleans, Louisiana

PSI 2001 Annual Meeting Abstracts

Papers

Establishing a computer system for recording male sexual dysfunction within the psychosexual service and andrology service

Kevan R Wylie, Consultant in Sexual Medicine, Porterbrook Clinic, Consultant in Andrology, Royal Hallamshire Hospital, MSc & PGDip Course Director, Porterbrook Clinic, Editor-in-Chief, Sexual & Relationship Therapy, Sheffield, UK

Male erectile disorder (MED) is managed by many specialties including urology and psychiatry as well as genito-urinary medicine, gynaecology & family planning services. Our city of half a million subjects has two main services in urology and psychiatry. The referral of patients with male erectile disorder to one of two different services within the same city for assessment and treatment meant that patients had different assessment procedures and treatment options. Shared care guidelines with primary care were developed in an attempt to guide clinicians in primary care about which service was most appropriate for their patient. This was important as the waiting list time extended at one point in time to 23 months for one service. The opportunity arose for the leadership of both services under one physician which allowed the development of a shared assessment schedule for patients attending either the organic service in andrology/urology and the psychological service in psychiatry/psychotherapy. This ensured thorough assessment (after training of clinicians) of both physical and psychological factors. Shared investigative procedures and treatment options of both physical and psychological therapies meant that patients had a similar opportunity at either site. Staff were placed at both sites to cover each option but the distribution of provision of psychotherapy time to physical treatments time varied across sites.

A shared database in Access 2 was created to capture data from both sites. This was found to be cumbersome given the sixteen page assessment. A software system was written in Access 97 which developed appropriate screen forms to capture data from the paper recorded assessments. This allows for comparisons to be made across the services. It will also allow in time for developments and possible changes in recording data from patient assessments. These will be considered in the presentation.

Over 1,000 patients are entered onto the database from the two services and some of the data comparing the patients who are referred and use the two services will be presented as well as examples of other computer generated reports which we have started to produce from our software.

The Psychopharmacology Algorithm Project at the Department of Psychiatry, Harvard Medical School

D. Osser, Harvard Medical School, Taunton State Hospital, Taunton, MA; S. Chaves; L. Rowe; R. Patterson; M. Ahmed; S. Brown; J. Grunwald; J. Musgrave; D. Najarian; C. Patel; A. Dantzler; E. Angeles; K. Nelson; H. Chang; R. Johnston; M. Brasier; R. Bayog

Method: Six psychiatrists and their clinical teams at Taunton State Hospital, a tertiary care facility, volunteered to participate in a 10 month pilot feasibility study designed to determine if physicians could, as part of routine care, consult evidence-supported, interactive algorithmic psychopharmacology treatment guidelines on the Internet prior to making major medication changes, and in addition record outcome data on these trials. Physicians were asked to choose the treatment that they considered best for each patient: there was no requirement to follow the guideline recommendations. The reasons for deviating from the guidelines were recorded.

Data were collected on 27 treatment trials in 21 patients. Diagnoses of patients receiving the trials were schizoaffective disorder (18), schizophrenia (7), and depression (2). In 11 trials, the algorithms were not consulted, but baseline data on outcomes were collected on these trials. In 16 trials, the algorithms were consulted and the clinicians found recommendations for the patients at 9 different decision points.

Results: At the end of ten months of the project, 16 trials had been completed and 11 were still in progress. 8 (30%) had a successful outcome, defined as improvement sufficient for discharge. 2 (7%) had a partial success, 4 (15%) had an unsatisfactory response despite an adequate trial, 2 (7%) had an unsatisfactory response due to intolerance of the medication, and 11 (41%) of the trials were still in progress. In this small sample, there was no significant difference in the outcome of patients treated in the pre-algorithm phase compared to the algorithm consultation phase. Of the 16 trials with algorithm consultation, 13 followed the algorithm recommendations and 3 did not. The reason for not following in the three cases was patient refusal. The clinical teams also collected baseline and end-of-trial data on five rating instruments measuring symptoms and functioning. However, this data was generally not collected at the proper time. For example, baseline data on each scale was obtained an average of 12 to 34 days after the start of the trial (range 1-96).

Conclusions: Internet-based electronic decision-support tools can be used in a busy public hospital with difficult, treatment-resistant patients to promote consideration of psychopharmacology algorithms at the point of service. However, outcome assessments must be simple and practical, such as a retrospective global assessment. It was demonstrated that it is possible to evaluate the quality of medical decision-making, using evidence-based reasoning as the benchmark. Also, the reasoning and outcome performance of individual psychiatrists can be compared. A larger study is planned.

An electronic bulletin board to enhance residency communication

Simon Kung, M.D., PGY-1 Resident, Kemuel L. Philbrick, M.D., Program Director, Maria I. Lapid, M.D., PGY-4 Resident, Mayo Clinic and Foundation, Rochester, MN

Since 1997, the Mayo Clinic Psychiatry Residency Program has utilized resident-developed intranet web pages with administrative, clinical, and educational content. Information on this website includes announcements, schedules, policy guidelines, clinical and administrative forms, and electronic submission of faculty and rotation evaluations. Despite the success and usefulness of this website, one of its drawbacks was that new information had to be routed to the web caretaker, who might not be able to post the information right away. To remedy this situation, we embarked on enhancing the website to facilitate real-time resident-to-resident and program director-to-resident communications by adding an easy-to-use electronic bulletin board.

Three applications for this electronic bulletin board emerged: 1) to provide a general forum for communication among residents; 2) to provide an up-to-date resident-generated collection of clinical advice or "pearls"; and 3) to allow the program director to inform and remind residents of new and existing policies, as well as to provide links and information regarding awards and fellowships. Traditionally, e-mail and paper mail had been used to provide these functions, however, these methods resulted in cluttered mailboxes or lost messages. By implementing the electronic bulletin board, the residents have campus-wide access from any intranet browser to a central repository of information without having to log in to their e-mail. Also, any person can post information to the electronic bulletin board and the message would be instantaneously displayed, thus bypassing the website caretaker.

An additional use of the electronic bulletin board was to collect pieces of information -- such as clinical advice or important administrative policies -- and organize them into a dynamic on-line handbook. Using a paper bulletin board paradigm, messages can be posted unlocked or locked, and can be set to expire automatically or be removed manually. Messages can be periodically reviewed, and the best ones elevated to a higher permanent status, for example, "pearls". The flexibility of this system allows a residency program to provide continuous improvement and timely dissemination of information.

Preliminary feedback for the electronic bulletin board has been positive. The software will be further refined, and we believe it will be an important addition to enhancing communication within the residency program. We are willing to share our in-house developed software with other interested organizations; it requires Allaire's Cold Fusion 4.01 web database software and an appropriate database such as Microsoft's SQL Server 7.

Increasing informaticians in behavioral healthcare: The promise of distance learning

Sarbori R Bhattacharya, Fellow, Center for Quality Innovations and Research, Department of Psychiatry, University of Cincinnati, Cincinnati, OH; Naakesh A Dewan, Executive Director, Center for Quality Innovations and Research, Department of Psychiatry, University of Cincinnati, Cincinnati, OH; Nancy M Lorenzi, Assistant Vice-Chancellor for Health Affairs, Vanderbilt University Medical Center, Nashville, TN; Arlette Lefebvre, Toronto Hospital for Sick Children, Toronto, Canada

Psychiatric informatics is an emerging discipline in the medical informatics arena. This is due, in part, to the rapid integration of technology into psychiatric practice and education. There is a tremendous need for developing a critical mass of behavioral informaticians to guide the nearly 40,000 psychiatrists in the U.S. In the absence of a brick-and-mortar training program, online didactics could be the possible solution.

Distance learning permits the students to fit instruction on desired topics at their own rate and can follow their development with immediate feedback on examinations. Not only is this format time efficient, it is also cost effective. Information on the distance learning site is easily updated and can be managed by a small group of people. For multiple site organizations, input can be received and distributed within a matter of minutes.

The effort to build a psychiatric informatics curriculum incorporates a three tiered framework developed by the International Medical Informatics Association, which includes healthcare professionals, type of specialization in health and medical informatics, and stage of career progression, based on educational degrees. The Association's 1999 Spring Congress outlined a list of recommendations for informatics core competencies in a recent White Paper. Among the list of suggested requirements were software use, ethics, and principles of privacy, confidentiality, and security.

Although there are multiple general medical informatics distance learning courses available online, there are currently no psychiatric equivalents. Although the medical informatics programs incorporated parts of the aforementioned core competencies, no program included them all. The intention is to include all these competencies into the proposed Psychiatric Informatics program. Five topics in the proposed curricula have already been developed into structured lecture material: (1) Barriers and Resistance to Informatics (2) Evaluating the Impact of Behavioral Healthcare Informatics (3) Managing Clinical Care in a Pervasive Computing Environment (4) Roles of the CEO and CIO in Behavioral Informatics, and (5) Technology Infrastructure.

In conclusion, a distance learning initiative based on established medical informatics programs is being developed for psychiatry. An evaluation framework will be developed to measure the effectiveness of the program and will be modeled after other evaluation efforts. Rapid knowledge dissemination can be achieved with distance learning, and it is hoped that the online program will become a respected source for knowledge.

A project to apply computer technologies to psychiatric practice in Italy

Luciano Conti, Associate Professor, Psychiatric Institute, University of Pisa, Pisa, Italy; Gabriele Massimetti

In the attempt to promote the development and application of computer technologies to psychiatric practice, and to stimulate, through appropriate promotional initiatives, the spread of such technologies in the psychiatric services operating in Italy, the Committee for Information Technology in Psychiatry (Comitato per l'Informatica in Psichiatria, CIP) was constituted in 1995 on the initiative of 4 university psychiatric Institutes, i.e. those of Milan, Pisa, Rome and Turin.

The first phase of the CIP project was to define the Minimum Basic Data Set (MBDS), a common body of information that can be shared by all users, i.e. that would allow a communicative base among users independently of the specific operative modes, and the different theoretical approaches. The MBDS is the minimal pool of information that is necessary and sufficient for a definition of the essential characteristics of the patient and of the therapeutic intervention.

As far as the software is concerned, the CIP policy is that each user is free to develop his own conventional model of data collection and his own software on condition that they:

Considering the requests received from numerous users not in possession of software, the CIP adopted already existing software for the computerised management of the case record, developed by us at the department of Psychiatry of the University of Pisa which, having grown in parallel with our involvement with the development of the CIP, responds practically to the requirements envisaged by the CIP itself. The system thus created has been named Sistema Informativo per la Documentazione dell'Assistenza Psichiatrica (SIDAP, Information System for the Documentation of Psychiatric Care). The main characteristics of the system are modularity and flexibility, which allow the maximum of personalization of the data collection.

In this presentation the authors describe the characteristics of the SIDAP and of the CIP project.

Automated, technology-facilitated communications in behavioral health

Michael D. McGee, M.D., President and Chair, AdvantaCare, Inc., Danvers, MA

This presentation will review the literature on the use of automated communications to improve clinical outcomes through promotion of treatment adherence, self-care, and timely clinical intervention to address variances from optimal outcomes. A robust literature exists confirming the efficacy of automated systems that both provide and collect information from patients, caregivers, providers and others. I will review novel communications protocols for various psychiatric populations, specialties and services, discuss the many benefits of these protocols, and review challenges and barriers to implementation that clinicians and administrators must overcome.

Three behavioral health EMR

Daniel Deutschman, MD, Case Western Reserve University, Jesse Wright, MD PhD, University of Louisville, Steven Hyler, MD, Columbia University

In the mid 1990's, the Institute of Medicine opined that electronic medical records (EMR) would supplant written clinical records in the 21st century because of their superior quality and productivity. At that time, three psychiatrists began implementing such systems.

The first began by building a system with "File Maker". In 2000, he implemented Sequest Technologies "Tier" system into a large multidisciplinary clinic. In 1996, the second implemented MedicaLogics "Logician" into a university department of psychiatry. The third began by building a system in Microsoft Access. Iterations were implemented in 1995, 1998 and 2000.

Each system has been a success, exceeding the expectations of the implementing psychiatrist. The EMR have been used in inpatient, outpatient, private practice, clinic, single and multiple site facilities.

All are clinically comprehensive. All print prescriptions and lab requests. Preprogrammed reports track patient symptoms, side effects, lab studies and medication trials providing decision support for work with treatment resistant patients. EMR can monitor population data elements such as demographics, utilization, diagnosis, suicidality and clinician behavior. Some facilitate impromptu queries, e.g. "find all patients on Cylert" (in order to warn about liver damage).

Experience has been gained with business functions including billing, insurance treatment plans, and simultaneous scheduling from multiple sites. In one system patients enter clinical and rating scale/outcome data directly into computers. This is immediately accessible to the treating psychiatrist.

Comparing the three EMR will emphasize:

  1. Choosing, customizing and adapting commercially available EMR to site specific needs.

  2. Obtaining organizational buy-in.

  3. Setting up a development team.

  4. Integrating a computerized record into therapy.

  5. Overcoming implementation obstacles.

  6. Patient and professional satisfaction.

  7. Impact on quality of care and productivity.

Panel Discussion

Psychiatry it is a-changin'

Joel Yaeger, MD, University of New Mexico; Thomas Kramer, MD, American Board of Psychiatry and Neurology; Ronnie Stangler, MD, University of Washington, Seattle; moderated by Robert S. Kennedy, Medscape

It's 2001 and the once booming dot com world has dramatically changed. In the last few years, the Internet has provided a boom to businesses and created a new but fragile economy that has become more tenuous over the last year. The impact on psychiatry is the subject of discussion. This panel will explore the changing landscape of the the Internet and technology on the practice of psychiatry, business of psychiatry and psychiatric education; what changes positive and negative have occurred over the last two years; and what challenges lie ahead.

Breakout Session

"Electronically enhanced" clinical treatment of anxiety disorders

 Carroll Cradock, Ph.D., Director, Ambulatory Behavioral Health Services, Toby S. Perlman, Ph.D., Program Manager, Deaf and Hard of Hearing Program, Advocate Northside Health Network, Chicago, IL

Many changes have occurred since the times when Freud could meet with self-paying, wealthy patients in his home-based office multiple times each week for an unlimited course of treatment. In the 21st century, patients, psychiatrists and therapists may drive significant distances to arrive at the office where treatment takes place. Most patients have very busy schedules filed with work, family and personal obligations. Most doctors and therapists also have very busy schedules, especially at the office where they must attempt to compensate for reduced third party reimbursements and the accompanying increased paperwork and phone work. To further complicate matters, managed care companies significantly have limited the number of face-to-face, office-based therapeutic encounters in which patients are treated. The cognitive interventions used to treat anxiety disorders, however, need not be restricted to a face-to-face, office-based encounter.

By redefining the therapeutic frame to include the creative and clinically sound use of technology solutions, we have developed templates for producing innovative, individualized and inexpensive therapeutic tools specific to each patient's treatment plan. This presentation will focus on the "electronically enhanced" clinical treatment of adults and children who have a diagnosis of Anxiety Disorder or who experience significant symptoms of anxiety outside of their doctor's or therapist's office. During this breakout session, participants will learn how to collaborate with their patients in the office to develop personalized clinical tools and how to guide patients in the use of these portable and practical cognitive tools outside the office. Specific examples will include the innovative use of audiotapes, videotapes and patient-generated web pages to provide cognitive restructuring, relaxation exercises, coping strategies and hypnotic induction. Our consistent clinical experience is that these tools are extremely effective in promoting recovery, preventing relapse and enhancing patients' roles in actively managing their own care without exhausting the restricted payor resources and limited face-to-face encounters we face in the 21st century.

Posters

Assessing hand held computer use among psychiatry house staff and faculty

 Anoop Karippot, MD, Department of Psychiatry and Behavioral Medicine, University of Louisville School of Medicine, Louisville, KY

Objective: Hand Held Computers (PDA) have become increasingly popular in recent years. While there has been interest regarding the potential for Hand Held Computers in medical education, no studies have described HHC use among Psychiatry house staff and faculty in an academic setting. We describe the prevalence and patterns of HHC/PDA use among Psychiatry house staff and faculty in a University setting.

Methods: All psychiatry house staff and faculty in the Department of Psychiatry at the University of Louisville School of Medicine were surveyed. Basic demographic data, type of HHC, the operating system (OS) used, medical purposes for which the HHC was used, as well as the type of medical software installed on the HHC was obtained.

Results: 172 surveys were given, with 102 respondents (response rate 59.3%). 32 of the respondents (31.4%) owned an HHC/PDA, and of these, psychiatric faculty contributed 37.5% of the HHC. The largest individual group was the PGY-I's with 25% of the HHC/PDA's. The PGY-II's and PGY-III's provided 9.4% and 12.5% respectively. The PGY-IV's showed an increasing trend in the use of HHC/PDA with 15.6% use. The junior faculty (75%) outnumbered the senior faculty (25%). The majority of HHC/PDA users used a Palm Pilot device (78.1%) as opposed to a Handspring Visor (9.4%), TRG (9.2%), Casio E series (2.3%) and other HHC (1%). 93.5% of HHC/PDA users used the Palm OS as opposed to windows CE OS (2.3%). Medical formulas (24.8%) and drug references (23.8%) made up most of the medical uses among HHC/PDA users. Epocrates was the most commonly used drug reference. Medical text references (5.7%), inpatient tracking (3.8%) and evidence-based medicine were poorly utilized if at all.

Conclusion: Most psychiatry house staff and faculty do not own a handheld computer. Among those who do own a HHC/PDA, the majority are the PGY-I's, and most use either a Palm Pilot or a HHC compatible with the Palm OS. HHC users appear to rely on their computers for references, and there is little use of HHC's for either medical knowledge or evidence-based medicine. The potential is great for increasing the utility of hand held computers among psychiatry house staff and faculty for medical education and clinical practice, particularly in the realms of medical knowledge and evidence-based medicine. There is a greater need to promote advanced medical informatics awareness among the house staff and faculty to better serve the patients and improve medical education.

The specialty board in the 21st century: Informatics at the American Board of Psychiatry and Neurology

Thomas A. M. Kramer, M.D., Senior Vice President, Paul Whittington, Director of Information Services, American Board of Psychiatry and Neurology, Inc., Deerfield, IL

The American Board of Psychiatry and Neurology has recently initiated a number of projects in Informatics. They include the construction of a computer test center, and by the time this presentation will be made, the first examination, in Neurodevelopmental Disabilities, will be given in that center. This computer test center will not only give computer-based examinations, but also function as a laboratory for research and development for future testing technology. In addition, major modifications and expansions are planned for the ABPN website including an intranet for directors only, with possible expansion to examiners and committee members. ABPN also uses data base software to track its diplomates, and item banks for test questions for all 16 written examinations that ABPN currently administers. This software is under ongoing revision and may be considerably different in the future as newer technologies are applied. The presenters will present a brief overview of the current state of information technology and application at ABPN, and invite the participants to provide input as to ways that ABPN could further improve or enhance its use of information technology to fulfill its mission as a specialty board for psychiatry and neurology. In addition, if time permits, we may be able to demonstrate the testing software during this session or in a subsequent poster session.

Using prescription writing/medication tracking software in clinical practice: A nine year experience

Arnold M. Rosen, M.D., New York, NY

The author reports on a 9 year clinical experience using prescription writing/medication tracking software, Medication Management Software (MMS). MMS can print prescriptions, record and update prescription data files and provide practice statistics. Thus writing prescriptions is made more efficient while transcription errors are practically eliminated.

A unique feature of MMS is an "intelligent" module (SmartSig) which can understand over 99% of the "Sig:" directions. This allows the computer to accurately model the way prescriptions are written by hand. There are no templates to select, icons to click on, or boxes to check. To illustrate using an uncommon example, if the clinician writes for Zoloft 50 mg., and types in the "Sig:" field, "1-1/2 qd alt 2 qd", SmartSig will echo back and later print on the prescription, "(1) & (1/2) Tabs Daily, Alternating With (2) Tabs Daily". The program will "recognize" that (on average) 1 and 3/4 tablets are required per day and the patient's daily dose of Zoloft is 88 mg.

A number of benefits flow from this intelligent SmartSig module without requiring extra data input. (1). The program (not the user) calculates how many tablets or capsules are needed for a particular time period. (2). MMS generates a report listing all patients who will need medication renewals during a selected time period, allowing for closer follow-up. (3). Practice management and prescription evaluation studies can examine not only the number of different medications prescribed but their average doses as well.

The most significant clinical benefit stems from MMS's ability (with SmartSig) to abstract and instantaneously display a flow chart of a patient's entire prescription history (RxTimeLine). When a patient decompensates or relapses after a relatively long period of stability, the clinician has to shift from a "maintenance" to an "active treatment" mode. A thorough review of clinical records is needed to determine what medications were used in the past: when?, in what doses?, with what other medications?, side effects?, outcome? Often this is a time-consuming and confusing process. With the RxTimeLine flow chart, what is akin to a list of highways and mileage can be converted into a road map, allowing clinical details to stand out that might otherwise be overlooked.

Patient response has been very favorable. A survey of 130 patients showed 96% approved the use of the software in the management of their medication.

Personal digital assistants in psychiatric residency training

John Luo, M.D., Mark Servis, M.D., Richard Montgomery, M.D., Department of Psychiatry, University of California, Davis, Davis, CA

The practice of medicine requires management of enormous amounts of information. The information demands to provide timely and appropriate care are tremendous, involving storage, retrieval, and access of patient care information as well as reference texts. Personal digital assistants (PDAs) provide one mechanism to facilitate this need accurately and with minimal effort. They provide an excellent medium for patient tracking, medical calculations, storage of reference materials, lookup of information, and even Internet access. In particular, their mobility and ease of use are clearly solutions to this information management need.

Residency training programs are faced with similar information needs. Collection of data on patient encounters ensures that residents have met the RRC requirements. Distribution of lecture times, grand rounds, and other meetings to several groups requires significant personnel resources. Access to reference materials at the time of decision making may have an impact on patient care. Contact information needs to be available for supervision. Much of this information in resident training fit the portability and quick access that PDAs provide.

In this poster, several innovative solutions involving PDA use will be illustrated. Resource information such as telephone numbers, pager, and e-mail addresses is provided to all residents for easy lookup. Electronic sign-out on the consultation and liaison service via a sign-out PDA intermediary facilitates dissemination of patient care information without direct resident communication. In addition, several key concepts in the strategy for implementation must be utilized to ensure compliance. A pilot group of residents designed the policy and procedures to minimize resident resistance. One-on-one training was conducted using peers to facilitate use. Finally, selected residents provided leadership to enforce and promote use of the PDA.

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Last updated: June 15, 2001
URL: http://www.techpsych.org/01/abstracts.html