This paper proposes how research based developments are needed to use current computer technology to optimize the psychological/ psychiatric service. Research areas that can contribute to an optimized and integrated service within a personal electronic patient record are: intelligent assessment systems with feedback routines, matching and booking functionality, and evidence based intervention teaching for therapists. The proposed benefits of this research integration is a positive spiral of improved patient satisfaction, reduced cost of treatment, and a basis for better research. An integrative development program is proposed.
Patients in need of psychological care are faced with a challenging maze of how to
find the best treatment for her/ his current problem. Knowledge about diagnostic
assessment[
The primary health provider does assess the patient by ICPC-2e International Classification of Primary Care into approximately 30 different possible psychiatric diagnoses (in the p and z domain) before referring to a specialist. Thus, the detailed assessment of the patient has to be done by the psychologist/ psychiatrist. The first sessions with the specialist will therefore be used to further diagnostic assessment. Once the problem is focused, it may be necessary to refer the patient to another therapist who specializes in treating the present problem. In the process time goes on before the patient gets the treatment and the patient have little control and responsibility during the process.
When the patient finally gets to the right treatment, there is seldom routinely
monitoring of the treatment process. Consequently, there quality of treatment is
seldom documented, and there will not be routinely actions when the patient does not
respond to the treatment or when the patient has reached the goal of treatment. These
decisions are fully left to the clinical judgment, which is of low reliability without
objective decision support [
The missing possibility for the patient to fully or partly drive the assessment
process online also makes it impossible to enjoy the benefits of new technology where
treatment is computer assisted [
Most of patients’ self reported information is used for research. This information is often collected by a researcher and used to analyze groups of patients. Researchers and their employers often consider data from assessment forms their property and will not easily let other have access to their data. Valuable individual longitudinal information will not be made available to the patient when going to a different site for later treatment. Further, data that can document the effect of a treatment may potentially be hidden or manipulated in the care of the treatment provider.
In all, there is a large potential for alleviating patients’ suffering and improving efficiency by letting patients do their own assessment in a PEMRS.
Patients are often referred by their primary physician to a local psychiatric clinic or a list of private practitioners. The list of private practitioners contains is not dynamic and will therefore not be updated on availability, or specialty accreditation. Therefore the patient is often randomly assigned to a therapist. Consequently, valuable time may be used in searching and waiting for a good matching specialist. Current internet technology could make this process much faster and accurate.
Therapists, especially in private practice are often not under supervision. No therapist
has supervision based on routine reporting by the patient. They get counseling in the
areas they request. Consequently, the patient has no control of this process unless
letters of complaint are written; witch is less likely when a patient is under much
distress. A regular monitoring of patient response can alarm supervisors to cases
where the therapist does not handle the situation [
The research based knowledge is not easily accessible for the clinical practitioner. Research articles are time consuming reading. The computer technology has availability to present audiovisual material simple and focused provided that systems are prepared for collaboration with objective information on the patient. To the best of my knowledge, there is no such system available. As a result, there is no way to ensure that the practitioner is updated on the empirically validated intervention for the present problem.
In this section I will propose some areas where already established knowledge could be integrated into a PEMRS to improve efficiency in the treatment of psychiatric care.
Since the 1860’s, psychometric research has developed systems for assessing patient
characteristics. The development of solid self report instruments is a long and
laborious process, including measuring the normal variation of specific symptoms.
These instruments provide invaluable clinical guidelines for the treatment provider.
However, top level self report systems to guide the patient down to the bottom level
electronic assessment form are yet to be ready for free use[
Quality assurance [
Once a patient has focused the problems into a diagnosis, a major set of problematic symptoms or personally anchored problematic pattern; research based knowledge can be used to match the right treatment [30, 31]. The clinical psychiatric research have compiled lists of treatments that are evidence based or empirically supported [32] for specific psychiatric diagnoses. There are emerging systems for certification of therapists within specific treatment packages. A natural place to collect information about therapist’s location, available sessions and accreditation status would be in a PEMR site. Consequently, the PEMR site can include booking systems for direct booking of a therapist.
Recent research has developed algorithms for identifying patients at risk for treatment failures. Supervision of such cases can reduce the likelihood of failures. Studies of the treatment process have given necessary and detailed insight of the most effective change agent. Process data can be the patients own feedback at various intervals in the treatment, observer data, or therapists’ judgments during the treatment[33]. A PEMRS should therefore include procedures for suggesting empirically supported methods to most efficiently alleviate the patients suffering.
Process research centers in Trondheim and Bergen are collaborating with the American Psychological Association (APA) in developing an empirically based fundament for future teaching videos to be delivered over the internet. The crucial point for timing of learning intervention is just before the therapist sees his patient. If the patient can drive the assessment procedures, then the therapist can focus on being ready with the relevant tools for the current problem. A future incorporation of the Norwegian-APA system can base the delivery of therapist demonstrations on the current patient’s PEMRS assessment.
A focus on PEMRS research has enormous potentials for improved efficiency in psychiatric treatments, thus potentials for large national savings. The potentials of the PEMRS to improve patients feeling of control of their own healing also have valuable benefits in itself.
However, the process of integrating the different fields of research within the psychiatric field into a PEMRS produces many challenges. Firstly, researchers will need to agree on a common goal. The principles of a PEMRS may challenge fundamental philosophy in existing research. Some assessment systems are commercially based on being paid by the treatment provider.
Secondly, state funding is essential for the development of the psychiatric part of a PEMRS. Without active participation of the funding part, short cuts into commercial shallow systems may undermine the integrated potential of a PEMRS. Further the participation of psychiatric professionals with research knowledge and insight into computer systematization is an essential ingredient in the process. Such personnel is limited and may hamper the development.
Further developments in PEMRS should include the psychiatric field and work on getting the necessary funding to get an optimal functioning. 27. Brown, G.S. and E.R. Jones, Implementation of a feedback system in a managed care environment: What are patients teaching us? Journal Of Clinical Psychology, 2005. 61(2): p. 187-198. 28. Percevic, R., M.J. Lambert, and H. Kordy, What is the predictive value of responses to psychotherapy for its future course? - Empirical explorations and consequences for outcome monitoring. Psychotherapy Research, 2006. 16(3): p. 364-373. 29. Hannan, C., et al., A lab test and algorithms for identifying clients at risk for treatment failure. Journal of Clinical Psychology, 2005. 61(2): p. 155-163. 30. Lambert, M.J. and D.E. Barley, Research summary on the therapeutic relationship and psychotherapy outcome, in Norcross, John C. (Ed). (2002). Psychotherapy relationships that work: Therapist contributions and responsiveness to patients. (pp. 17 32). London, Oxford University Press. xii, 452 pp.SEE BOOK. 2002. 31. Beutler, L.E., C. Moleiro, and H. Talebi, How practitioners can systematically use empirical evidence in treatment selection. Journal Of Clinical Psychology, 2002. 58(10): p. 1199-1212. 32. Leichsenring, V.F. and U. Ruger, Psychotherapy and Evidence Based Medicine (EBM) - Randomized controlled vs. naturalistic studies: Is there only one gold standard? Zeitschrift Fur Psychosomatische Medizin Und Psychotherapie, 2004. 50(2): p. 203-217. 33. APA-Division-of-Psychotherapy. Position Paper on Funding for Psychotherapy Research. Position Paper on Funding for Psychotherapy Research 2006 March 7, 2006 [cited 2006 March 7, 2006]; Available from: http://www.divisionofpsychotherapy.org/FundingPositionPaper.php.