Category: SOS Blog

Decision Making 101

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Last week I mentioned the scholarly book,  The Rise of Homo Sapiens: The evolution of modern thinking, written by our friend Fred Coolidge and his colleague, Tom Wynn. This week’s read has been a popular book (also about the brain and cognition) titled How We Decide by Jonah Lehrer.  Both books focus on the executive functions of the brain. The Rise of Homo Sapiens explores how those functions may have developed and evolved and How We Decide focuses on how we utilize the Executive — both important issues in psychology and neuropsychology.

Not surprisingly, one of the most crucial responsibilities of the Executive is to decide not to behave, that is, to withhold or inhibit action. When I decide not to emit an expletive, even though I am angry, to avoid further inflaming a confrontation, I have utilized that part of the brain which makes me human…the one that keeps me from behaving purely on the basis of my emotions. The prefrontal cortex allows me to inhibit behaviors that might be destructive to me and to others.

On the other hand, when I am in a situation where it is perfectly safe to respond in a purely emotional fashion, that same Executive sometimes keeps me from doing so. Rather than taking a deep breath and enjoying a sensory experience, such as a bicycle ride, to its fullest, my prefrontal cortex questions how much pollen is in the air today and complains of the humidity that makes the air seem so heavy. Sometimes, we cannot do even the simplest of things without analyzing every aspect of, and all the implications for, that behavior.

It sometimes seems to me that our country is filled with people who have not learned how to moderate or inhibit behaviors. They see or hear the statement of some other person and cannot help but react. Their Executive does not kick in until they have already done their knee-jerk reaction. Then they either regret their comment or spend an inordinate amount of time analyzing or defending it so they can feel justified.

I used to think it was just pundits, bloggers, news analysts and elected officials who reacted without benefit of the Executive, but as I read the newspaper and see the comments of my neighbors to events in our community, I become more and more convinced that we have not effectively learned when it is best to behave on the basis of our emotions and when some logic would be more useful. We may have evolved the brain structures and capacities that allow us to behave in balanced fashion, but we seem as a nation to do a poor job of educating ourselves on how to utilize those abilities toward the general good. I usually don’t even read rants any more…and I’m doing my best to avoid reading pieces written by the Chicken Littles of the world. My own tendency toward negative emotions and thinking needs lots of logical balance plus the input of other folks who always see the glass as half full.

In the world of behavioral health services and practice, I sometimes see my colleagues and customers fail to utilize the executive functions of the brain to best advantage. Some impulsively rush to action taking a bit of information provided and implementing suggestions therein immediately. “The stimulus bill says we need to buy CCHIT certified EMRs, so we are doing so now! No, the ones we see are not designed for behavioral health. No, they are not particularly easy to use. But we will have a certified EMR.” Some behave in just the opposite fashion. They do not like the message they hear, so they avoid information about it. They withhold response to the extent that they do not inform themselves about the choices they will have to make in the future. “It will be ten years before anything actually happens. I’ll retire before that goes into effect. None of this pertains to me.” Somewhere in between lies a moderated response that may include ‘wait and see’, but informs itself in the time spend waiting and seeing. 

How We Decide is a good read. It might remind you of some of your own decision making strengths and weaknesses.

How do you decide to comment on this and other blog articles or not to do so? Let us hear what you have to say. Just click on the title of this article and enter your comment in the box at the bottom of the page. Your thoughts are always welcome, whether modulated by the Executive or not!

EMR, Decision Support and Modern Human Thinking

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Our book group had the pleasure of reading and having a visit with the author of The Rise of Homo Sapiens: The evolution of modern thinking, by Frederick L. Coolidge and Thomas Wynn. Fred has been a friend and colleague for the past 35+ years and is Seth’s long distance bicycling buddy. He is currently experiencing the joy of a “new” career arena and direction after 30 years as a psychology professor at University of Colorado, Colorado Springs. 

The thesis of his book is that early Homo sapiens became modern humans because of the evolution of cognitive structures and processes, probably caused by additive genetic mutations, that gave us significant advantage over our Neandertal counterparts. The book uses anthropological evidence to explore how the working memory model of psychologist Alan Baddeley may well have evolved.

For those of us who are not cognitive psychologists or anthropologists, one of the interesting aspects of this book is the hypothesis that language is not what gave Homo sapiens the leg up in adaptation. Rather, the ability to think in a fashion that allowed for planning, for the development of the “what if” scenario, for the creation and use of symbols, and other related cognitive tasks moved us along the path toward becoming human. Executive functions and the ability to withhold responses mentally and behaviorally may have become the keys to us reaching the top of the food chain.

As I read The Rise of Homo Sapiens, I found myself simplistically making analogy between the brain’s working memory and a computer’s RAM. The ability to keep information in my awareness, to be considered and acted upon, seems to me to be a portion of what we use computers to accomplish…an extension of what our brain can do for us…much as working memory became an extension for Homo sapiens of what the brains of earlier hominins had been capable.

For many of us, the computer has become a tool that gives us rapid access to information previously outside our realm of knowledge. We utilize this tool in our daily work, in doing research (of the shopping, term paper, and scientific study types), to communicate with friends and family members, to share our photographs, to do the billing for our psychology practices, to make purchases, to get the news…and to keep us multi-tasking at an absurd rate. Generally speaking, this tool extends our cognitive and behavioral capabilities, allowing us to do more work that is often of a higher quality than we were able to accomplish without it.

As with most other things these days, my thinking comes inevitably back to the electronic medical record (EMR) and its relentless incursion into the lives of medical and mental health professionals. I am repeatedly surprised by the strong resistance to use of EMRs. I fully understand that cost will be an obstacle to hospitals, community behavioral health organizations and to some medical providers. I do see that changes in workflow necessitated by use of medical and behavioral health EMRs will initially slow down the work that the provider of healthcare services can provide, perhaps even diminishing the amount of direct consumer contact that can be accomplished in a day. And I do recognize that change is hard for all of us.

But I also know that development and use of our Case Manager product almost eighteen years ago renewed my enthusiasm for doing psychotherapy. Those of us working in South Florida were among the first hit by managed care and the need to submit treatment plans and clinical status reports for our patients. The process of using a computerized clinical record program, connecting my treatment plans to progress notes and assuring that my diagnoses were truly consistent with the problems and symptoms presented by my clients made me a more conscientious psychotherapist and helped me keep the therapy process on target.

Behavioral Health EMRs have come a long way since then. Medical EMRs have come even farther. The products now allow the gathering and accumulation of a great deal more data on each patient, including lab reports, x-rays and prescription history. Even more important is the fact that each of these products in some way provides decision support for the provider. This can range from safety alarms to decision trees to structures within which you can build your own unique reminders and supports. The products may provide recommendations on evidence based treatments and standards of care.

The largest objections to EMRs that I have heard go something like this: “I am a highly trained professional and I do not want a software product telling me what to do.” “No matter what is programmed into that machine, it will not be a better provider of care than someone with my expertise and experience.” What I have heard from mental health providers is that their unique relationship with the consumer is what creates the healing. Indeed, I remember my strong belief that one of my strengths as a psychotherapist lay in my ability to generate alternative behavioral options for my patients. In fact, my creativity in the generation of alternative courses of action and means of implementing and maintaining those courses of action was part of my unique effectiveness as a psychologist.

Or was it? Is a list of alternative recommendations produced by a computer program any less effective for a patient than the one generated by me…or by my internist? If the computer remembers to include everything that the current research data support as treatment for the diagnosed condition when my harried clinician forgets something, will the reminder be any less useful to me in treating my illness? And even it my doctor does not purchase a product with built in decision support…or chooses not to use the decision support tools…won’t I benefit from the results of my last blood work, my chronic conditions, and my list of medications all being immediately present as I discuss my fatigue and whether I am getting enough protein.

But, you ask, is this so important in mental health treatment? Are there really so many factors for me to consider that I need a computer to keep it all straight? Of course, you have a wonderful memory. You can recall details of your patients’ lives that were shared with you ten years ago without even reviewing the files. But, do you remember that you made this specific recommendation for change six months ago and that your patient became quite anxious when you pursued it and that you decided not to press for movement in that direction? Or do you only recall this after you make the same disturbing suggestion today? Or was it your last patient who had that reaction? That note is a little hard to read….

If Executive Function of the brain and the use of working memory are indeed what have made us uniquely human, perhaps we will decide to utilize brain extenders where possible to improve the care we provide. Imagine, our own ability to weigh and choose options facilitated by electronic tools. Add EMRs to our toolbox and provide better, more cost effective care. Or maybe that is just for physicians…

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Data Security, Backup, and the HITECH Law

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A question on one of the psychology listservs I follow got me thinking, yet again, about data security…and backup. The writer asked about the proper procedures to follow when patient psychotherapy treatment records are permanently lost. The question pertained to how the counselor in question should respond to the loss of all of their patient data from a mental health clinical record software program. Since we provide one such program, my attention was immediately attracted.

The other listserv members addressed three issues: recovery of the data from the hard drive, backup of the data, and re-creation of the records from scratch. Because of our experience with customers losing data due to computer failure, I focused yet again on data backup and database recovery. Added to my thoughts this time are the HIPAA requirements for securing protected health information (PHI) and the increased penalties in the HITECH portion of the stimulus bill (ARRA) for breach of privacy and security of PHI.

It is likely that you all remember that HIPAA requires healthcare providers (including psychiatrists, psychologists, social workers, mental health counselors, and community behavioral health organizations) to have in place procedures for securing the PHI of their patients. Most mental health workers with whom I am familiar focus on the privacy aspect of this protection; they see it as their responsibility to assure that the consumer’s information remains private. HIPAA also mandates that providers and their organizations have in place plans to protect the security of their physical data.

The National Institute of Standards and Technology (NIST) has produced Special Publication 800-66-Revision 1, “An Introductory Resource Guide for Implementing the HIPAA Security Rule.” A quick search of this document finds that the words “loss of data” are mentioned on pages 38, 77 and 98. The first mention is in a table describing the necessary contents of the Contingency Plan for data security, including a Data Backup Plan. The sections of this document that focus on the Contingency Plan and the Disaster Recovery Plan are the ones most concerned with electronic data storage.

If your organization, including your private practice of psychology or psychiatry, does not have a Contingency Plan and a Disaster Recovery Plan, however brief, you are living dangerously. And, of course, you must implement your plan to secure your PHI, not just have a plan.

How does this pertain to you? Let’s start with your data backup plan. What is it? Who in your organization is responsible to implement it? What are the consequences if it is not implemented?

One of our customers,   W. E. (Bill) Benet, Ph.D., Psy.D., Clinical Psychologist, Gainesville, FL  WEBenet.com | Assessment Psychology.com describes his experience and current backup strategy.

“I mentioned Eco Data Recovery in my previous note because I had to use their service a number of years ago after the hard drive on my main office PC mechanically failed and became inaccessible while backing up to a tape drive, corrupting the data on the tape. Fortunately, Eco was able to recover all of the data from the hard drive, by disassembling it in a ‘clean room’ and scanning the data off the individual platters. Luckily, the data on the hard drive hadn’t been corrupted, but it very easily could have been, and I would have lost years of billing records and reports.”

“But what about data that has become insidiously corrupted without being immediately obvious?”

“Today, I employ a simulated RAID backup strategy involving nightly network backups to two external USB drives, as well as from one PC to the other, AND continuous 24/7 incremental offsite backups, using Carbonite. Hopefully, if corrupted files are discovered days or weeks later, those incremental backups will save the day, at least for a while.”

Here at SOS Software, we all too often run into an organization where the principals thought they had an excellent data security plan, only to find out that their plan had not been effective or had not been implemented by the person(s) who were responsible to do so.

One of the obstacles we run into is the common belief that “it can’t happen to us.” We all know this is magical thinking; of course, it can and does.

Another often-believed myth is “I don’t really need to worry about data on my PC; data can always be recovered from a hard drive if there is a problem.” While this belief is sometimes true, it often is not. If the files lost when a computer crashes are in a complex, proprietary relational database, they sometimes are totally irretrievable. They are not text files where parts can be grabbed and some sense made of the data.

Our product uses Sybase ASA as its engine because that database creates a transaction log that can allow us to completely recreate every keystroke the user made…if the log file is intact. In fact, we use Sybase because of this capability to completely recreate the database if it is necessary to do so. As long as we have a usable starting point, we can restore the entire database from the log file…if we have an intact log file.

Two problems can intervene. 1. With our products as with many others, if the backup is done while the database is running, certain of the files are not backed up because they cannot be accessed completely. Some backup software products will tell you they can back up even when the program is running. That is not true with SOS products. 2. Hard drives often fail gradually becoming literally “flaky” over time. If key sectors of the log file are lost, it is impossible to recreate the database from the log, even if there has been no overwriting of the database.

Also, sadly, even folks who believe they responsibly make backups, never test those backups to assure they can be restored properly, and they often use the same backup medium overwriting old backups. If the hard drive has been gradually failing, destroying parts of the files as it goes, then backups of those bad files become bad too…all of this over time with no noticeable degradation of performance of the database.

Then the catastrophe occurs…a power surge or some other event causes a crash of the hard drive and the database will not restart when the computer is rebooted!

As indicated by comments on my post of November 19, 2008, The Indispensable Data Backup, among my readers are many folks who are sophisticated computer users who are responsible enough to use multiple methods of backing up their patient data. Using a rotating system of backing up with permanent, non-incremental backups created periodically and stored off-site, is crucial. The strategy we recommend is in document 125 on our main web site.

If you have never tried restoring from one of your backups, you have not completed the process. Unverified backups are useless backups. Useless backups equal insecure PHI. How big a risk taker are you?

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EMR Variations: Is certification necessary?

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We spent the holiday weekend at the Georgia Tandem Rally, our favorite organized bicycling event. This year, 102 tandem teams from 15 states rode the tandem-friendly, hilly terrain around Athens, GA. During the 135 miles of riding, I had plenty of opportunity to reflect on why I enjoy riding a tandem bicycle so much…especially in the company of other tandems.

Tandem bicycling used to be the venue of the middle-aged, but younger folks with children riding along have become much more common participants. The result of the addition of these younger riders to the mix is a wonderful continuum in strength, speed and power. Even those of us who have never been fast (having started our tandem careers around our half-century birthdays), are able to be carried along by the power and enthusiasm of the younger riders. There are few more fun things for this otherwise very slow cyclist than a double pace line of tandem bicycles moving quickly along a traffic-free country road. We are all made stronger and faster by the quick moving youngsters and no one feels bad when we drop back to do our own thing at our own slower pace. Variation in team strength and endurance is part of what makes this kind of riding fun; each individual tandem is a successful team riding to their own particular tune.

In fact, the dramatic variation in tandem teams reminded me strongly of the similar variation among our customers. We have in our mix many solo providers, even more mid-sized groups, and a significant number of large groups and small to mid-sized agencies. Mental health providers are notoriously independent types; even when they work in groups and agencies they find or found organizations that fit their personal styles. In the 24 years we have been doing our business, we have been amazed at the varied ways in which our customers utilize the tools we provide…behavioral health practice management and EMR software. Indeed, I would venture to say that we have no two customer organizations who use our products identically. Discussion on our user group will readily confirm this observation.

This same variety exists in the arena of software providers. There are companies large and small providing products that also vary markedly in capabilities and in price. Those of us who are small benefit greatly from working with our larger competitors; we are swept along in the tide of change adding the essentials to our products so our smaller customers can continue to meet the ever-more-complex requirements placed upon all provider organizations, no matter their size.

Given all of this variety, I find myself wondering how many behavioral health practitioners will actually need certified Electronic Medical Records (EMR) in order to provide their services and to be able to share their records with other providers electronically. When I look at the list of functionalities and interoperability criteria required of certified products in the ambulatory health arena, I wonder what proportion of our customers could even begin to make use of all those features and communication capabilities…and how many actually require those feature sets in order to do their jobs well. They might be required by funding sources to purchase certified products, but if they are not part of an integrated healthcare organization, they are unlikely to actually need such products.

I spent a good deal of time participating in a work group that developed a behavioral health-specific profile for software products that conforms to the major criteria in the ambulatory EMR set. That conformance profile was adopted by HL7. I must say that the profile includes comprehensive feature sets for the most complex of behavioral health community organizations. It is significant overkill for most individual and group providers.

The Certification Commission for Healthcare Information Technology (CCHIT) has a work group developing criteria and test scripts for certification of behavioral health EMR products. While a draft of these criteria is due by August 2009, this certification will not be available until 2010 at the earliest, and possibly later. This timing and the limited funding available in ARRA to behavioral health providers makes it unlikely that most mental health provider organizations will be able to qualify for ARRA funding to buy behavioral health-specific products. 

My question to myself and to you is, does that really matter? If Behavioral Health certification were in place today, how many of you would be shopping for a certified behavioral health EMR to implement immediately? How many of you have even begun to think about whether and how this whole move to electronic medical records will impact your practice of psychology? of psychiatry? your community organization?

My experience of our customers, of the successful teams of people who currently provide mental health services in various settings in the U.S., is that you will continue to do so with or without certified EMRs. You will find behavioral health electronic medical record products that fit your budget, your workflow and your way of providing services, and that can share essential information with other providers and the healthcare system at large, whether or not the products used by your communication partners are certified.

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Bike MS…and fundraising for healthcare

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We just returned from bicycling 125 miles over the course of a weekend to raise money for the Central Florida chapter of the National Multiple Sclerosis Society. Seth has been doing this ride or one for the North Florida Chapter since 2001 and I have joined him for all or part of the weekend of riding on four occasions. This is one of three charities that we contribute to in some significant fashion and it is the only one for which we do fundraising.

After a challenging several months of work in the behavioral health software community struggling to keep up with the volumes of information being produced about how the economic stimulus act (ARRA) will affect our industry, I was very much looking forward to a weekend fully engrossed in cycling…no thoughts of mental health billing or behavioral health electronic medical records. We have been training for the last couple of months so we could comfortably do the ride in what has already become blistering heat here in Central Florida. The thought of a weekend spent outdoors with other cyclists just enjoying cycling for a worthwhile cause was very pleasant to look forward to.

The weekend met most of my expectations, but there were also some surprises. We started and ended at Bok Tower Gardens, a beautiful botanic garden and National historical landmark in Lake Wales. We had good, if hot weather and the road conditions were excellent. We rode 78 miles on Saturday and 47 miles on Sunday. We were among 1200-1300 cyclists and 300 volunteers who participated in the event. There were more riders this year than last, but fundraising was down by a good deal. We won’t know how much for another month, but the poor economy has certainly affected the success of most riders at raising money. Even so, some of us did raise a bit more than we did last year. Corporate sponsorships were down and in-kind contributions were limited. The result was there were fewer and less well-stocked rest stops and cold, packaged breakfast in place of the usual hot breakfast we have come to expect. There was all the usual talk of bikes and rides and travel to ride some more. The Saturday evening dinner and celebration was as inspirational and moving as always. MS is a disease that has,  in some fashion, affected all of us who participate, and the commitment of the people in the room was magnificent.

Riding a bicycle, even in the company of many other riders, gives lots of opportunity for thought and reflection. This ride was no exception. And the healthcare environment in which we find ourselves brought my thoughts to the friends who struggle daily to live with MS…and why it is that programs to support them in their struggle and research to find a cure depend so much upon charity. What is it about us as a nation that allows us to believe that health care…even for chronic debilitating diseases that occur through no fault of our own…is a privilege rather than a right? Why do we take it for granted that those afflicted with many diseases, who need assistance their health insurance does not provide, should get that help from not-for-profit organizations dependent upon fundraising rather than from their health insurance…or not get it at all? Why is it acceptable to us that many of the bankruptcy proceedings forced upon middle class Americans occur because of a long illness and medical expenses that could not be borne? Why are we so unwilling to join the ranks of most of the industrialized world paying more in taxes to assure that we all have the healthcare we need when we need it, without fear of losing our life savings and our homes?

I hope that my careful eating and regular cycling help keep me healthy so I will experience a long life with a rapid decline at the end. The thought of relying upon our current healthcare system and being able to pay for my own care in the face of an extended illness frightens me more than I can say. I hope we soon come to a place where it is not necessary for any American to confront that fear.