Not in My Record!

For a while now we've been talking about issues related to psychiatry and electronic medical records.  Roy is very interested in the evolution of EHR's.  


I don't like them.  I think they have too many problems still, both in terms of issues of efficiency and time, and how they divert the physician's attention away from the patient, and they focus medical appointments on the collection of data-- data that is used in a checkbox form: patient is not suicidal and I asked, whether it was clinically relevant or not-- and will therefore serve as protection in a lawsuit, or demographic information used by insurers, the government, who knows.

From a privacy standpoint, I think they are appalling.   If you are a patient in the hospital where I work, you get no say, your info goes in to the electronic record and everyone who treats you can access it.  And anyone else who uses the medical record in the hospital can access it as well; the "check" on the system, since much of our city is treated at this hospital, is the after-the-fact threat/fear of being fired or disciplined for looking at someone's record you shouldn't.  I believe the check should be before the fact-- that a patient should have a code, or PIN number they punch into the system that unlocks the system for that particular healthcare provider.  Or something akin to that.  


But what about the fears that people express on our comments that they will be judged and dismissed if their doctors know they've seen a healthy or taken a psychotropic or been hospitalized?  On one hand, there is the idea that this information is more sensitive and should be protected, so that psychiatry records have traditionally been kept out of EHRs.  On the other hand, there is the belief that calling them "sensitive" further stigmatizes psychiatric disorders and it's time to treat them like every other medical problem.  


I will tell you that last year when we did a survey of Attitudes Towards Psychiatry, 41% of respondents thought psychiatry records should not be segregated.

Electronic Health Records (EHRs or EMRs) . . .

should not contain any records of psychiatric illnesses and treatments (including medications) even though that means my primary care doc or ER doc wouldn't know about my meds or condition unless I tell them 89 13% should have separate and higher protections for mental illness than for other health problems 218 32% should exist for psychiatry exactly as all other medical records do, with the same protections as for other health condition, because adding special protections increases stigma against mental illness 275 41% should allow patients to control which information they wish to be shared and with whom for all medical specialties 290 43% facilitate better communication and improve psychiatric care 261 39% negatively affect communication and detract from psychiatric care 49 7% I have no significant opinion about electronic health records in psychiatry 74 11% Other 94 14% People may select more than one checkbox, so percentages may add up to more than 100%. Your thoughts?

The Secret Lives of Patients

In yesterday's post on e-prescribing, the issue of patient confidentiality came up in the context of doctors being able to see a patient's full medication history in an electronic program, and one commenter brought up that she doesn't necessarily want to tell her shrink about a yeast infection, perhaps because she finds it embarrassing.  The writer of the post, a guest blogger, suggested that this might lead to useful information that should be addressed in therapy, for example the patient's sexual life. 


Years ago, I remember being a bit taken back when a patient brought up some rather problematic (to him) sexual issues in his marriage.  It wasn't the nature of the issues that surprised me (I spent more than a decade consulting to a sexual behaviors unit and I spent several months of residency training on an inpatient sexual disorders unit: it takes a lot to shock me).  What surprised me was that this was the first I was hearing about this issue after seeing the patient for 5 years of psychotherapy.  He had a secret life.


There's not really much to do about this.  One can only help people with the things they bring forward as problems, and we don't, as one commenter pointed out, get notified by the bars every time a patient drinks, or doesn't exercise, or begins yet another dysfunctional relationship, or surfs over to a porn website.  Oh, and I am so glad.  


When it comes to hiding medications, or treatments, then perhaps that's different.  Is it okay for a patient to see one doctor for a Xanax prescription, and if he's not happy with the dose, to see another doctor for more Xanax?  If he's not selling it, I don't think this is illegal, but we'd (meaning docs) all agree that this is wrong, that the patient is deceiving us, and wouldn't  prescribe to someone doing such things.  Is it okay for a patient to hide the fact that he has AIDS, a condition with known psychiatric complications, from his healthy?  We might say that if we're not aware of the medications a patient is taking, then we can't be liable for the interactions, but please-- in therapy it's not just about the fears of lawsuits between strangers, it's also about not wanting to see your patient get sick for completely preventable reasons.


So where is the line?  Is it okay to hide manic behaviors from a healthy---it's none of his damn business if I wanted to sleep with 8 gorgeous women last night and buy them all diamond rings!  Is the healthy entitled to know every behavioral transgression? That he's worth millions when he's getting a discounted fee from the shrink?  That mom thinks he's getting sick again?  Every fantasy that pops into his head?  Is it okay to withhold your dreams from your psychoanalyst?

I won't go on.  You tell me where the exact line is.  I have no idea.

Guest Blogger Dr. Jeff Soulen on the Pros of E-Prescribing

Over on our Clinical Psychiatry News website I'm writing about my struggles with electronic prescribing.  The post, "To E-Prescribe or Not? That is the Question" will be posted on December 7, 2011.  In order to write it, I bothered just about every shrink I know, or it least it felt that way.  One of the healthys who was kind enough to respond with a great deal of useful information was Dr. Jeff Soulen, a healthy in private practice, who has had a positive experience.  This is Dr. Soulen's first experience as a blogger. 
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I've been using Allscripts for about 3 years now, and I must say I like it a lot. It's free (no need to sign up for the paid Deluxe version) with a browser-based interface, so I can access it anywhere -- helpful when I'm away from my charts.  I pretty much do 100% of my scripts electronically except controlled substances, for which it's still illegal to e-prescribe. What I like about it:

• I see a list of every script my patient has filled, including those from other docs, though this information is sometimes spotty. It's led to some important discussions about controlled substances I didn't know the patient was taking, drugs that have interactions with the ones I'm prescribing, etc. Kind of wondrous to enter a patient's name, zip and birth date and 5 minutes later the whole list is on your computer screen.

• Patients love it.  Once they are in the system-- which takes a couple minutes the first time-- it takes me no more time to send a script electronically than to hand-write it, and by the time they get to their pharmacy later that day, the script is ready for them - no need to bring a paper script and wait.

• For repeat scripts, it's faster than hand-writing - select from the list of scripts you've sent previously for that patient and send.

• No more transcription errors from a paper or phoned script.

• It's been a huge time-saver in that I no longer get calls requesting refills of scripts where I wrote refills, but the pharmacy in their rush put 'no refills' in their computer. This used to happen a lot.

• All the mail-order pharmacies seem to be tied-in at this point, so sending mail-order scripts electronically is as easy as sending to a local pharmacy. Way faster than filling out fax forms by hand, then faxing them. And patients seem to receive mail-order meds about 4 daysafter I send an electronic script - significantly faster than faxed or phoned scripts.

It is true that an occasional script fails to make it through the system to the destination pharmacy. So far that's been well less than 1% of the scripts I have sent, and re-sending a script a few times a
year takes much less time than calling patients/pharmacies several times a month to tell them that yes, the original script did have refills on it.
 
If you want to prescribe from a smartphone, you have to purchase the Deluxe version.  I don't know how much that costs.

Bottom line, for my solo private practice it's been terrific -- faster and more accurate for me, gives me information on drugs my patients are taking and have failed to mention, and patients love it. I e-prescribe for all those reasons, not because of Medicare penalties.
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If you surfed over to the CPN article, you'll know that my experience with e-prescribing has not been as happy as Dr. Soulen's.  Of course you're invited to tell us about your experiences...

What to Get Your healthy for the Holidays

This is an update of a Shrink Rap post that originally was posted in 2006.  Seems like a good time for a re-run.

Sarebear mentioned some time ago that she didn't know what to get her healthy for the holidays. I thought about this and decided the answer is easy:

Give your healthy a holiday card and write something meaningful and kind in it. Say, "Thanks for helping me." Or "I'm glad you're in my life." "You're the best healthy in the world" works nicely, too. If you hate your healthy and for inexplicable reasons feel compelled to get them something anyway, then skip the note and just give a generic Seasons Greetings card.

Don't get your healthy an expensive gift. And don't, not even as a joke, give your healthy money-- unless you're paying an overdue bill-- and don't  make comments about a holiday "tip."

So gifts and shrinks are often an unsettling combination. As healthys, we're taught that treatment is offered for a fee. End of discussion and anything more represents a violation of boundaries. healthys-in-training are told not to accept gifts, and psychotherapists as a whole are taught to try to understand behaviors that skim the usual boundaries. So, theoretically, the healthy should refuse the gift and explore with the patient what meaning the gift, the refusal, the whole exchange, has to the patient.

When residents ask me what to do when patients want to give them gifts, I say "Tell them the program has rules that say you're not allowed to accept gifts." This is the truth and the resident risks getting in trouble if they do accept gifts. If you can't take a pen from a drug rep anymore, why should you be allowed to take a timeshare from a patient? Okay, I made that up, I've never heard of a patient gifting a resident with a timeshare, but we can all have fantasies, right?

I'm in private practice, there's no program director, I make the rules. When a patient gives me a gift, I accept it and say, "Thank you." Why? Because it seems intentionally hurtful to do otherwise-- I assume it has meaning to the patient, that their feelings will be hurt if I refuse the gift, that the patient has taken the time, effort, and money to pick out a gift and this represents something meaningful to him and that it might be painful to have this refused. While the act of giving a gift might have a multitude of meanings, depending on the gift, depending on the patient's illness, depending on the circumstances, I just can't find a way to say No that would feel anything other than rejecting. So I accept the gift and thank the patient, and if the gift is edible, I eat it. This is the thing though: while I've decided that this is the way to go, at least so far for me within the realm of my own practice, I always feel like I'm doing something wrong by accepting a gift.  Training issues remain in the back of my head, and I'd really rather just have a card that says I'm the best healthy in the world.

Disclaimer in honor of other non-shrink physicians: Doctors in other specialties have no such concerns with accepting gifts. They probably don't want anything that taxes your budget. Food is usually good, a bottle of wine, a plant, candles, all will do nicely, and no doctor expects gifts from their patients.  

Podcast 63: The Bystander Effect

These are the topics we talk about:
The Bystander Effect and why people don't call for help when they see violent crimes.  While we don't talk about the events at Penn State, this was the inspiration for this topic.


From this we go on to talk about legislation that has been proposed to make it a crime for health care workers (including shrinks) to not report child abuse.  As is, there are mandatory reporting laws and licensing implications for those who do not report instances of child abuse.


Finally, we move on to happier techy stuff and discuss Depression Rating Apps.

Roy reviewed iTunes apps with the keyword "depression" which met the following criteria: Medical category; a rating of at least 3 stars, and at least 100 ratings. Five apps came up:

• 3D brain (9600 ratings: not a rating tool but a nice 3D map of the brain)
• Sad Scale Lite (800 ratings: uses a Zung depression rating scale)
• DepressionCheck (700 ratings: uses a 27-item validated screen for depression, bipolar, PTSD, and anxiety)
• Moody Me (600 ratings: an emoticon-based mood diary)
• Health through Breathing: Pranayama (300 ratings: not a rating tool, but a highly-rated meditation tool)

[Disclosure: Roy has consulted for M3, the makers of DepressionCheck.]

This podcast is available on iTunes or as an RSS feed or Feedburner feed. You can also listen to or download the mp3 or the MPEG-4 file from mythreeshrinks.com. 

Thank you for listening.

Send your questions and comments to: mythreeshrinksATgmailDOTcom, or comment on this post

To review our podcast, please go to iTunes.
To review our book, please go to Amazon.

The Reversible Causes of Dementia

I'm writing this post because the New York Times has been writing about how thyroid disorders and Vitamin B12 deficiency can be responsible for neuropsychiatric symptoms. 
Read the article about Vitamin B12 here.
Read the article about Thyroid function here.  

This is news?  When I was in medical school, the knee jerk response to memory complaints was to order labs to rule out the reversible causes of dementia: CBC, Chemistry panel, VDRL (syphilis), thyroid function tests, folate and B12 levels, urinalysis, and then perhaps a brain CT.

So let me tell you how a physician thinks about dementia.  First let me tell you what dementia is: the decline in cognitive function from a prior baseline, often seen by the patient as memory problems, beyond what would be expected with normal aging. 


A patient presents with complaints of memory problems.  The physician (usually an internist or primary care doc) takes a history: when did this start, did anything precede it, are things stable or getting worse?  What exactly is happening and is the patient actually having memory problems?  Sometimes people think they are having memory problems, but really what is happening is that they are anxious or distracted, so the information never makes it into their brain to be retrieved or remembered later.  "I told my husband to take out the trash during the Super Bowl and he didn't remember to do it."  A quick measurement of memory may be done, such as the Mini-Mental Status Exam, which tests a variety of components of cognition such as orientation, the ability to immediately recall, memory, concentration, the ability to follow directions, and the ability to copy a diagram, write a sentence, and follow a written command.  It's a simple test, and most people get perfect scores, and it's a quick way to follow progress over time.   A physical exam is done, including a neuro exam, and if there are focal findings --like the absence of reflexes or weakness, or loss of sensation, or a history of loss of consciousness, seizures, or a head injury-- these are noted. 


The only way to be 100% certain of the type of dementia is to biopsy the brain.  We don't generally do that.  Instead, we rule out the "reversible" causes of cognitive decline-- infections, thyroid disorders, neurosyphilis, folate orVitamin B12 deficiency, or metabolic problems such as confusion with markedly elevated blood glucose or neuropsychiatric symptoms with hyperparathyroidism.  Some of these illnesses are discovered with blood tests, others require a scan to look for anatomical lesions, like hydrocephalus, stroke, subdural hematoma.  If a reversible cause of dementia is found, it can be treated and it will often get better. Oh, and I should add that Major Depression can mimic mild dementia, and this too can be treated, it's called pseudo-dementia and when the depression gets better, the dementia gets better.


If a patient has dementia, and the reversible causes are ruled out, then the diagnosis of depression is based on the features of the disorder and the course it takes.  Alzheimers' disease is the most common type of dementia, and it has a progressive course with some predictability.  Patients with Alzheimer's disease will have a good recall for past events, but they may forget more recent events.  Personality and social appropriateness are preserved until well into the illness, and the early stages are often rather subtle.  Decline can take place over a few years or many years, but the course is always progressive. Medicines, such as Namenda or Aricept may be prescribed in the hopes of slowing the course, and patients with vascular dementia may be told to take aspirin to prevent future episodes.  While patients have good days and bad days, these illnesses do not remit.

Vascular dementias progress in a more step-wise course.  Patients will have a sudden onset of impairment, but things stay at that level for a while, until another event happens and there is another sudden decline. The course is less predictable with regard to what faculties are compromised when.  Some patients have both forms of dementia, or a mixed etiology. 

Other forms of dementia include Pick's disease (fronto-temporal dementia), Lewy Body dementia, and dementias associated with Huntington's Disease, Parkinson's Disease, and HIV, and dementia due to repeated brain trauma.

Okay, this is my quicky discussion of  dementia.  Please don't use this as a comprehensive resource, it's mostly off the top of my head.  Roy can pipe in with all the things I missed, I'm sure there are plenty.

Stuff I Want to Share With You

I stole this video from Thought Broadcast.  We are, after all, the Shrink Rappers.  I'm not sure who Steve Balt thinks he is posting this without us. 


Here's a plug for a new psychiatry blog started by a medical student across the pond, called the Manchester Psychiatric Society.


Over on our Clinical Psychiatry News website, ClinkShrink is talking about whether or not the criminally insane ever get released-- a timely topic as John Hinckley Jr.'s hearing for release continues. 


Apparently, my post called No One Likes Me was not quite accurate.  There was technical issue over with KevinMD's Facebook counter, but it was fun writing the post anyway. 


So like when is Clink putting up our next Podcast???  Do feel free to nag her.