EMR, Decision Support and Modern Human Thinking

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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