Where's the Love for Tablet PCs in Psychiatry?

For those of us that watched the original Star Trek series, we might remember that Dr. McCoy deftly pulled up patient records, read scientific reports, and prescribed medications all from the comfort of his electronic pen and tablet in the 23rd century. Has reality already caught up with science fiction? Previously known as the pen or slate computer, our most modern iteration of the portable, wirelessly connected, handwriting- and speech-recognition-capable computer is the “tablet PC.” Coined in 2002 by Bill Gates, two predominant form factors have emerged. The “slate” tailors toward pure mobility and resembles a writing slate. The “convertible,” which is typically bulkier but currently more popular, combines the slate with an attached keyboard. In many ways, the tablet PC seems to be a natural fi t with the digital transformation of clinical medicine. In fact, the Medical Records Institute’s 2005 Annual Survey of Electronic Health Record Trends and Usage Study reported that tablet PCs were the fastest growing mobile/wireless technology in the health industry. Two-year growth rates were reported at 80.4% compared to 53.9% for cell phones, 2.8% for laptops, and 0.8% for PDAs. However, adoption of tablet PCs in psychiatry is still slow; following is an examination of signifi cant reasons for this apparent lag.

The Psychiatric Emergency Room

The Diagnostic Evaluation Center at Western Psychiatric Institute and Clinic (WPIC) uses an electronic medical record (EMR), PsychConsult, to record all demographic, diagnostic, treatment planning, and prescription data. For the most part, physicians and non-MD behavioral health clinicians take paper notes during the patient interview and then go to the back offi ce to enter this data into desktop computers. In a pilot program, the team wanted to see if the promise of the tablet PC—the streamlining of workfl ow by direct data entry into the EMR during the patient encounter—could be realized. Although some applications may be designed with the tablet PC in mind, the PsychConsult application was not.

Their initial experiences have been instructive. For this study, the Lenovo ThinkPad x61 Tablet was selected. It is a convertible tablet that weighs 4lbs and retails for around $2000. This tablet PC runs wirelessly off of a secured server, with no patient data saved to the device. The application automatically logs off the server after 10 minutes of inactivity and requires the user to reauthenticate with a username and password. In addition, switching to sleep or hibernation mode on the tablet logs the user off of the server. During the pilot, only non-MD behavioral health clinicians are using the tablets. These behavioral health clinicians are tasked to accompany the psychiatrists during their patient interviews. This allows the clinicians to fill out the history of present illness, past medical history, and other information directly into the EMR while the doctors interview the patient.

Most of the psychiatric evaluation form can be filled out by the clinician during the interview. This substantially decreases the arduous task of copying written information into the EMR after the interview. However, this advantage has yet to be replicated in the single clinician or single physician interview. Most people are unable to enter data through the stylus as quickly as is possible via paper and pencil. Some portions of the EMR are fi lled out through radio buttons that are simple to click with the stylus, but this still requires breaking eye contact with the patient. Missed clicks and corrections to the handwriting recognition can be disruptive. The quantitative questions of how these disruptions aff ect both workfl ow and patient interactions have yet to be measured and will be the next step in data collection.

Security risks As tablets emphasize ease of access and mobility, they may also be more susceptible to theft. Unfortunately, this risk is real, and lost or stolen PCs containing sensitive patient information have received much publicity lately. In February 2008, a laptop computer containing medical information of 2,500 patients enrolled in an NIH study was stolen. It was reported that seven years' worth of clinical trial data, including names and medical diagnoses of patients, were on that particular PC. In May 2006, a laptop was stolen from an employee at the Department of Veterans Affairs. Although later recovered, the computer contained sensitive information of more than 26.5 million veterans and military personnel. It is clear that the use of PCs (tablet or otherwise) needs to be accompanied by the strictest password protection and data encryption possible. In both case 1 and 2 above, signifi cant additional security is aff orded by not storing patient data on the tablet itself, but leaving it on a secured server. Th us, the portable computer in that case would only have one screen’s worth of sensitive information that would disappear when it was turned off . Some additional, simple guidelines to securing portable computers are offered by Psychiatric News at http://pn.psychiatryonline.org/cgi/content/full/36/5/10.

Effect on the patient physician relationship

Regardless of security, the IT industry often touts the benefi t of real-time data entry via electronic charting; however, there are some drawbacks.

In the practice of psychiatry in particular, one should be concerned about the eff ect of using computers during clinical encounters on the patient-physician relationship. Although less disruptive than the tapping of a keyboard, maintaining eye contact while entering data with a stylus is still challenging for many clinicians. These concerns may be valid, as some early studies have shown that patients’ confi dentiality concerns, communication style, anxiety, and idealism are altered by computer use in the clinical setting. A group from the University of New Mexico School of Medicine hypothesized that overall patient satisfaction would decrease as their behavioral health facilities changed from paper-based to electronic charting (http:// tinyurl.com/4ez4cl). In the WPIC case above, these concerns are circumvented, as a clinician is entering data while the physician performs the interview in the traditional manner. We also see attempts to address this in the research case, in which patients were asked about their views on clinicians using tablet PCs. Before further adoption of the technology occurs, perhaps we should challenge the industry to support further studies like these to address how tablets aff ect relationships with our patients.

“Clunky” technology Naakesh Dewan, MD, internationally recognized psychiatrist and author of Behavioral Healthcare Informatics, lent his thoughts on the current state of tablet PCs in psychiatry. “Although the tablet tries to replicate the experience of a clipboard, the sad fact is the hardware, durability, user interface, information representation, and navigation have not been engineered yet to be as effi cient as traditional work,” he says, adding that, however, “information access is better, legibility is better, and a few other things are better.” He believes that the industry could do much better in supporting healthcare. “The problem with today’s technology, although a step in the right direction, is as clunky as the first model T,” explains Dewan. “In all other industries, technology either helps make more money, or save money, or fundamentally enhances the user experience or output.”

The tablet PC in research

Despite the hurdles tablet PCs and their users must overcome, the technology can have a huge positive impact on psychiatry practice when in the right hands and if these obstacles are taken into consideration. A recent study evaluated the use of the tablet PC to capture self-reported data from depressed patients directly into an electronic record, with the authors comparing traditional paper reporting to electronic reporting. They hypothesized that the tablet PC would help reduce time spent transferring data from paper to electronic record, decrease data collection and entry errors, and act as an acceptable substitute to patients. Th e authors found that symptom ratings on the QIDS-SR16 instrument were comparable in both paper and electronic forms. Interestingly, about half of the 80 participants with major depressive disorder found the tablet PC easier to use than the traditional paper format, and therefore preferable. In addition, study participants were asked to indicate their opinions regarding the use of a tablet PC by a clinician during an interview. They reported that 86.3% of participants indicated that they would not feel uneasy and that 78.5% of participants would not find it distracting to introduce a tablet PC into the clinical interview setting. One question that persists is whether patients would have answered as positively to clinicians using tablets if they had never been exposed to the tablet PCs themselves.

“Today’s healthcare technology is primarily a major risk with a 50% chance of success,” says Dewar. “We as physicians need to challenge the IT industry to do a lot better to assist healthcare.” Will the industry take a serious look at these challenges that could potentially ground the tablet PC? We seriously hope so.

Dr. Liang is a child and adolescent psychiatry fellow and chief resident of Ambulatory Services at Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center. His research focuses on the implementation of mobile technologies in the treatment of severe and persistent mental illnesses. Dr. Friedman is the director of the Mood Disorders Treatment and Research Program, University of Pittsburgh School of Medicine, Department of Psychiatry. His research has focused on psychotherapy, pharmacotherapy, and combination treatments for depression and bipolar illness. He has published numerous articles and book chapters on these subjects.