Ask the Doctor: Health2047 advisor and practicing physician Dr. Christine Stock has embarked on this direct input gathering project. Her mission is to assure that physicians inform everything Health2047 does and that the physician’s perspective remains central in developing companies with scalable solutions aimed at our biggest healthcare challenges. She recently spoke with Dr. Carlyle Chan, Medical College of Wisconsin psychiatry and behavioral medicine professor and vice chair of professional development and educational outreach. They discussed the difficulties of utilizing technological solutions in mental health treatment, unique patient privacy and digitization issues, the shortage of behavioral medicine specialists, and opportunities for change. Their conversation inspired this blog post.

Challenges for Behavioral Medicine and Technology

The field of psychiatry, like many medical subspecialties, faces important challenges and unmet needs in regard to extracting value from technology and leveraging the collection and measurement of data to advance the field.

Some impediments stem from the evolution of practice: defining what to research, honing-in on specific areas like depression or anxiety in terms of efficacy of treatment, variance in types of treatment, and coordination of psychopharmacological and psychotherapeutic approaches.

Inherent Complexity
For example, there are different forms of depression. Classifications for major depression can range from bipolar depression to persistent depression to treatment-resistant depression, with both physiological and environmental factors variously contributing to incidence. In regard to leveraging data and technology for better quality treatment, I think we’re a little bit behind some of the other medical fields that can be more methodological in terms of defining diagnosis and outcomes simply because behavioral medicine is so complicated.

That level of complexity extends to the technologies we use for patient referral and the flow of clinical information as well. To illustrate, I was on a committee for a community outpatient clinic a few years ago. One of our affiliates was a suburban hospital whose patients would be referred to us for follow-up after discharge from inpatient psychiatry. Even though we were both using the same electronic medical record (EMR) system, at the time, the system had separate inpatient and outpatient versions that did not interface. So, I’d get the referrals and I’d see the patients shortly after discharge, but I wouldn’t get any discharge summary.

Inpatient psychiatry is currently, on average, a five-day hospitalization targeting stabilization. Patients are basically started on multiple medications and sent out very quickly once they’re stable and compliant. So, I’d get patients who were on four or five different medications and I’d have no idea what was working. That would begin a whole process of trying to sort out what was efficacious and what wasn’t over the next several months.

Inpatient versus outpatient
For example, someone presents as psychotic in an emergency room and gets admitted. There’s any number of different reasons for psychosis: They could be schizophrenic, they could be psychotically depressed, they could be bipolar, they could have some type of organic brain syndrome. And these days, psychiatric inpatient hospitalization insurance is very limited. So inpatient physicians must make a quick assessment and probably load up on an antipsychotic and maybe an antidepressant. And then if there’s anxiety, they add an anxiety medication. If it’s evidently bipolar, they may add a mood stabilizer. The aim is to quickly make the patient become, for lack of better word, tranquilized and docile and maybe less suicidal.

Because insurance frequently limits the length of inpatient stay, psychiatrists need to quickly transition to outpatient care or sometimes to a step-down approach with a partial hospital or intensive outpatient program. But there’s rarely a clear diagnosis at this particular point. The patient is just less in need of hospitalization.

Such scenarios vary depending on where they occur and the patient’s insurance. And sometimes technology does help, particularly within a network. With the Medical College of Wisconsin regional health network clinics and hospitals where I work, everything is now on the same EMR system. The primary care physician has access to patient medical records including inpatient psychiatric information, so the electronic health record can be very constructive for in-network cases. If the patient comes from outside the system or they’re in a different network, then trying to get their information hooked up is a little more laborious in terms of trying to assess history or locate their providers and access points.

Patient data protections and digitization
The uniquely sensitive nature of patient data presents another hurdle in healthcare digitization. When HIPAA rules were first introduced, there were varying state-level interpretations and modifications to increase technological access to medical data for software function. When I was working at the community clinic, for example, I underwent Suboxone training and learned that addiction records have a higher level of confidentiality than even HIPAA requires. When my employer was rolling out their EMR system, they initially made psych records available to everybody in the system, which violated these separate federal confidentiality provisions concerning addictive disorders.

After legal review, the immediate solution was to implement break-the-glass procedures: limiting access, but allowing for emergency authorization with careful identity monitoring, audit trails, and documentation surrounding the reason for record access. Wisconsin has since implemented a different type of coding for confidentiality and the break-the-glass system has gone away. There may well continue to be some state-by-state variations in how technologies manage patient privacy provisions and the flow of data.

The Covid-19 pandemic has temporarily relaxed some of the HIPAA regulations; and Medicare and many insurance companies have permitted billing for non-face-to-face encounters via phone and videoconferencing. This has been a necessary determination to decrease the spread of the contagion while still providing essential services.

Behavioral medicine dynamics
Beyond technological considerations, psychiatry has changed drastically in the in the last 20 years. There’s been enormous development in the role of medications that work for specific disorders and an increased focus on psychopharmacological practice even as we come to better grasp the role of social events in psychiatric illnesses. The old nature versus nurture question is not an either-or proposition. The findings of the ACE studies addressing adverse childhood events demonstrate that it’s not just biological or medical factors influencing the rate of psychiatric illness and responses to trauma. Pills can’t take care of everything; there have to be some real psychological and psychosocial interventions as well.

Even more pressing is the issue of psychiatric access. There are still a lot of barriers to behavioral treatment and access to care. And there’s a crushing shortage of psychiatrists and mental health professionals. This means the waits to get into outpatient clinics are weeks and months in many locations, particularly in rural areas. Compounding the issue is that fact that around half the psychiatrists practicing nationally are over 55 and approaching retirement.

A parallel issue arising over the past few years is that psychiatry has become a sought-after specialty and residency, but there are a limited number of residency programs and slots available around the country so many qualified and eager students simply cannot be matched.

I helped start two residencies in Wisconsin: one graduating three per year, the other four per year, with the first class graduating in June of 2021. So that’s seven new psychiatrists coming on the market. However, current projections indicate that Wisconsin alone has about a 250-psychiatrist shortage. So even expanding some of the residencies, while necessary, isn’t sufficient to address the urgent workforce needs.

The collaborative care initiative is one force multiplier to potentially increase behavioral health access and alleviate the workforce shortages a little bit faster. It involves training primary care physicians to take on psychopharmacological treatment of the more routine cases of anxiety and depression and possibly addictions.

Where technology can help
Like many other physicians, I see great potential for artificial intelligence tools to aid in reducing the administrative load that now accompanies practice. When I was working at a suburban clinic in the early days of electronic health records, I ended up seeing my patients back to back, and jotting some notes down for each. But then I’d have to stay an extra two hours to enter all my notes into the system at the end of the day. My fantasy is that at some point, as you talk to the patient, recording and language-processing tools will automatically enter progress notes into the system accurately and in real time.

While that’s my hope, the shortage of psychiatrists and lack of distribution and access to care predominate everything else. Even as we get new treatments and tools, who’s going to deliver them?

I enthusiastically encourage prospective doctors to pursue psychiatry and behavioral medicine not just because of national need, but because it is a great field. You get to talk to your patients and see them more often and for longer periods of time than other disciplines. And there’s a benefit to that in terms of developing your relationship with the patient and sharing the impact of your work.

For all the challenges, I think there are a lot fewer unhappy psychiatrists than there are internists and other doctors.

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