EMRs and Zombie Psychiatry

Are EMRs yet another example of an external influence that is changing psychiatry for the worse?

The following was originally posted to the HCPLive network blog Thought Broadcast.

I consider myself to be a fairly tech-savvy guy. I grew up in the 80s and computers have been a part of my leisure time, my academic life, and my work environment for as long as I can remember. But using an electronic medical record (EMR) is testing my patience.

More importantly, it’s yet another example of an external influence which is changing the practice of psychiatry. And not for the better.

I learned how to practice medicine from teachers who valued the essence of the interpersonal relationship between patient and doctor. What attracted me to psychiatry in particular was the fact that in this field, these unspoken and unquantifiable aspects of the doctor-patient dyad are paramount, much more so than in any other medical specialty. The patient’s subjective feelings about the therapeutic relationship—the patient’s unconscious transference of experience from past relationships into the present, for example—are as much a part of the therapeutic process as his or her verbal reports or directly measurable behavioral symptoms. The “soul” of psychiatry lies in this nonverbal interaction.

Moreover, this relationship transcends time. For as much as we like to bemoan the “15-minute med check” appointment, the truth is that fifteen minutes is plenty of time for an expert clinician to get an overall feeling for a patient—the “Gestalt” impression that informs the treatment process. By the same token, a one-hour session by a poorly trained clinician is nothing more than data gathering.

EMRs are changing how we document information. One could argue, correctly, that documentation has always been an important part of clinical care, and not directly related to the doctor-patient relationship. However, a well-written note (not to mention the exquisitely detailed psychodynamic case formulations from years past) can convey a rich trove of information about a patient’s history, symptoms, underlying pathology, and future goals.

The type of information we document in an EMR, however, is different. I’ve commented elsewhere that the ideal EMR for a psychiatrist would be a word processor and an encrypted hard drive. Nothing more. Just let me enter all the information that I think is relevant in a given session and save it for next time.

But EMRs weren’t designed for the psychiatrist or the patient. They were designed for administrators, billing experts, lawyers, insurance companies, and others who care more about the quantifiable aspects of the interaction (the diagnosis, the medication prescribed, the presence/absence of discrete symptoms) than about the patterns of symptoms, the clinician’s subjective assessment, and the hypotheses underlying the patient’s behavior which are being actively tested in the therapeutic relationship.

The amount of time it takes me to document everything that is required for “correct billing” of my appointments (and to double-check everything, lest I get a call from my administrator the next day to “fix the chart”) takes up virtually the entire scheduled appointment time.

But my concern here is not about the time it takes, or even about the nuisance of having to click on a few dozen boxes during each patient encounter, or open six different documents—in different formats, in non-overlapping windows—to see what’s happened since a patient’s last visit. (I like to think that I’m a quick enough learner to do all of that.) My concern instead is with how I’m now starting to think of patients not as human beings with interesting and complicated histories which inform my care, but rather as collections of symptoms which change from visit to visit.

EMRs demand measurement and assessment of patients on scales that are, for the most part, arbitrary, and which may be completely “off the mark” vis-à-vis what’s really happening in a person’s life. They ask us to quantify things that cannot be quantified, and distract our attention from what might be truly significant in the patient’s life at the time of the encounter.

Hey, maybe that’s okay. After all, it’s the monthly visits by patient 2010-00224, dx code 296.34, that pay the bills. And as long as I’ve checked the boxes next to “depressed mood” or “insomnia” or “feelings of guilt” (not to mention the other two-dozen boxes I need to check for his mental status exam and review of systems), and updated his problem list, and made sure I checked the box indicating he isn’t suicidal (never mind whether I actually asked him or not), that counts as “good” care.

But by this time, I’m not a psychiatrist. Heck, I’m not even a human, I’m entranced, soulless, and following someone else’s commands. A zombie. And patient 2010-00224 deserves more than that.