=Paper=
{{Paper
|id=Vol-219/paper-4
|storemode=property
|title=Personal electronic record systems in Psychiatric care; assessment, treatment matching, quality assurance, and research
|pdfUrl=https://ceur-ws.org/Vol-219/paper03.pdf
|volume=Vol-219
}}
==Personal electronic record systems in Psychiatric care; assessment, treatment matching, quality assurance, and research==
https://ceur-ws.org/Vol-219/paper03.pdf
Personal Electronic Record Systems in Psychiatric
Care; a Call for Integration
Jakob Valen12
1
Dept. of Psychology, Norwegian University of Science and Technology, 7491 Trondheim
2
St Olavs University Hospital,P O Box 3008 Lade, 7441 Trondheim
{Jakob Valen}jakobv@ntnu.no
Abstract. 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.
Keywords: psychotherapy outcome; matching; booking; psychotherapy
research; cost efficiency; feedback; monitoring; quality improvement;
information technology.
1 Introduction to the Problem
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[1-4], treatment availability and the best treatment[5] for a given problem
is distributed to various degrees in the population of primary care providers as well as
in the patient population. When the patient does get assigned to a treatment, the
matching with the patient and the treatment may be based on personally acquired
network knowledge. The procedures to in depth assess the problem as well as the
systems to document treatment response[6, 7] vary largely between providers. Details
from the patients’ previous treatment history is difficult to document in detail and
often impossible. The lack of systematic assessment procedures can make it random
whether the patient is offered the optimally empirically supported treatment
ingredients for the specific problem. Only 8 to 10% of American psychologists uses
computer supported assessment[6]. Finally, data for research on the efficacy and
process on the patient is limited to the data collected from when treatment started at a
treatment provider. Consequently, data from a naturalistic longitudinally study of the
patient is only possible trough a relationship to a research project set up for such
studies. With the recent scandals from researchers’ manipulation of data in mind, the
need for transparency and solid data storage can not be over emphasized.
In sum, the field of psychiatric care has large potentials for improved efficiency by
implementing a personal electronic medical record (PEMR)[8-10] witch includes 1)
systems for assessment, 2) treatment matching, and 3) empirically based teaching
systems for provider. These fields will be discussed in further details in the following.
1.1 Assessment and Monitoring
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 [11].
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 [12-15].
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.
1.2 Treatment Matching and Booking
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.
1.3 Provider Supervision
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 [16].
1.3.1 Teaching Systems for Treatment Providers
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.
2 Proposed Solutions
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.
2.1 Assessment and Monitoring
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[1]. Future research should
integrate current assessment knowledge into PEMR to deliver patients freedom to
assess their problems in a reliable and valid way, fully in control of their own process.
Quality assurance [6, 7, 16-23] in measuring the treatment response should be a
natural procedure in all clinical settings. Monitoring of treatment response provides
the ability to present important clinical feedback[16, 21, 22, 24-27] to patients as well
as the therapist. The benefits of incorporating such procedures in PEMR are therefore
obvious. In a PEMRS, the patient is in control and drives the monitoring [6, 16, 28,
29] independent of provider. The monitoring may be an incentive from the provider.
This solves the problem of transparency of therapist and treatment site efficiency,
since the patient can submit her or his data to any data collection they may want to.
2.2 Treatment Matching and Booking
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.
2.3 Provider Supervision
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.
2.3.1 Teaching Systems for Treatment Providers
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.
3 Discussion
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.
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