Clinical Computing: Challenges of the World Wide Web

The Internet is changing the world, with implications for the future of psychiatry (1). In a previous column, we described the basic trends that are directing this transformation, drawing examples from the worlds of science and business and extrapolating into areas of psychiatric work (2). We see four driving forces at work: the world's movement to the Web (the consolidation of information on the Web), the Web's movement to the world (increased access to the Web), managing the Web (the trend to facilitate management of Web information), and management by the Web (the trend toward use of Web-based information for management). In this column, we describe the challenges these trends create for psychiatrists and the steps we must take to avoid misfortune in the information age.

Challenges for psychiatry

The four trends are creating many challenges for the field of psychiatry, which we divide into three general areas. First, the increase in the amount of information circulated through computers will affect the type and quality of information that physicians and patients use. This process in turn will alter the attitudes of physicians and patients toward information. Second, the increase in the access that different people will have to computer-based information will not only increase the expectations that physicians should provide information, but also reduce the privacy of information transfer. Finally, increases in the use of computers to manage all types of information will be applied to the management of the delivery of psychiatric care. We expand on each of these areas, suggesting specific examples of how they might appear in psychiatric practice and steps that we must take to address these challenges.

A flood of information

The increase of available information circulated by computer will result in information flooding. As the entire world moves to the Web, more sources of information will be available. This expansion of sources will promote competition in which Web-based information sources attempt to present information more rapidly, in greater depth, or with greater emotional appeal so they can capture the attention of a larger share of Web users. Because almost no cost is involved in publishing on the Web compared with traditional means of disseminating information, we should expect to find a full range of sites, each of which employs a different presentation strategy.

Some sources will focus on in-depth, balanced, accurate information. Other sources will paint with broad emotional strokes, quickly popularizing the latest fad for diagnosis or treatment. Because so many different sources will be available, and because few will have a long history to build a trustworthy reputation, it will be difficult to categorize the reliability of any particular information source (3). Given the complexity and lack of central organization of the Web, it may be difficult to even find sources of information in the first place or, once found, to determine where particular information truly originates.

E-mail communications already have a reputation for spreading myths and unintentional misinformation, or even perpetrating hoaxes (4). Rapid electronic publication can lead to less review and less thoughtfulness, which can lower the quality of information even when reputable publishers attempt to move operations to the Web. It will take time for quality standards to develop in the electronic world. These deficits will be balanced by a greater availability of information that is up to date and that may have been inaccessible in a traditional publishing framework.

Psychiatrists will need to balance their approach to this information flood. We will need to access electronic information to remain up to date and to be aware of the concerns of our patients. This approach includes spending time learning how to find information electronically and familiarizing ourselves sufficiently with the medium that we are aware of some of the basic signs of unreliable information. We need to apply our skills of critical appraisal to all information, questioning the generalizability of data, the rigor of experimental methods, and the appropriateness of conclusions. Furthermore, we need to work with our patients to help them understand our approach to information so that they can more appropriately deal with any hype promulgated by the mass media (5).

Finally, we need to emphasize the development of critical skills in psychiatric training. As information exchange increases, no one will be able to keep up with all the advances in research or the newest theories. We must make sure that training focuses on instilling not only content-type information about psychiatric diagnosis and treatment, but also on process-type information about how valid information about treatment and diagnosis is generated and how we can direct a personal process of life-long learning.

Breaches in confidentiality

The theme of the Web's moving out to the world and increasing everyone's access to information raises the question of unauthorized or undesirable access to information. Clinical experience and research on confidentiality clearly demonstrate the importance of maintaining privacy in psychiatric treatment. Court rulings, expectations of third-party payers, review by peers and accreditation groups, and research efforts directed at determining outcomes all illustrate current pressures to divulge information garnered from a doctor-patient relationship that was previously considered sacrosanct. The demands of these groups for more information will only increase with increased use of the Web.

With this type of environment, it is likely that patients will be reluctant to disclose important information. The groups wishing to gain access to information will be indirectly present in every treatment session, affecting patients' perceptions of our agenda and our ability to engage therapeutically. Furthermore, the use of large, anonymous electronic databases raises questions about the potential for break-ins from computer hackers or even from authorized users who are perusing records not directly related to their work.

We will not be able to stop the trend of making information electronic, but as psychiatrists we have a responsibility to work to preserve the privacy and security of that information (6). Individually, we should learn about potential breaches in the security of information and what technical solutions, such as encryption technology, are available to defend against them. Most security analysts emphasize that the greatest risk to information is actually through approved users. Examples include the disgruntled employee who maliciously destroys or sells information or the careless user who inadvertently sends an e-mail or fax to the wrong location.

Education and familiarity with potential pitfalls are the best weapons against such dangers. Organizations also need to be educated about them and should develop policies to protect privacy. Reminders not to talk about patients in the hallway should be extended appropriately to communication by e-mail and other electronic media.

Finally, psychiatric organizations must be involved in crafting legislation related to these issues. The Fair Health Information Practices Act in the House (H.R. 52) and the Health Insurance Portability and Accountability Act of 1996 illustrate some of the guidelines that have been passed and are being discussed (7,8). Other recently proposed legislation includes the Medical Information Privacy and Security Act (S. 1368) and the Health Care Personal Information Nondisclosure Act (S. 1921) (9,10). We need to aim our efforts at ensuring that psychiatric experience is represented in the legislative process so that we protect the interests of our patients and our ability to appropriately treat them.

An expansion of management

The trend of greater management of activity through the Web extends the current attempt to manage clinical care. A pervasive movement exists to integrate health care delivery to provide more uniform, cost-effective care. In the guiding paradigm, the patient is viewed as a consumer and the physician as a provider of information and service who helps maintain a database of what is delivered so that administrators and managers can evaluate its effectiveness. The development of the Health Plan Employer Data and Information Set (HEDIS) and other guidelines from the National Committee for Quality Assurance illustrate this process (11,12). The process will be accelerated by all other trends described here: more networked information, easier access to networked information, and improved tools for information management.

Individual psychiatrists will need to respond by maintaining their sensitivity to the interpersonal milieu they establish with their patients. As we are required to place more information into computers in more rigid and mechanical fashion, we must work to ensure that this does not become our sole task. Goals of improved quality and efficiency are desirable, but as individuals we must continue to pay attention to the healing power of rapport and relationship that can be lost in the process of automation (13). Part of this task also involves working to establish boundaries around our work, setting limits in both law and custom, so that the fundamentals of our practice can be maintained. In addition, we need to work and train in the young science of informatics so that the information tools that are developed in the future will reflect more of our needs and the essence of our work rather than enforcing the oversimplified categorization toward which computers are predisposed.

Conclusions

Trends are bringing the Internet and the World Wide Web into the daily lives and work of psychiatrists. In our adjustment to these new technologies, problems will arise as our traditional expectations of information change. We cannot expect to trust information or its security the same way we have in the past. Instead of taking accuracy and security for granted, we will need to learn how we can maintain our current values in this new age through self-education (14) and political work. We will need to formulate a new balance between the demands of management and the familiar customs of care. Instead of avoiding this future, we believe that psychiatry must meet it and guide the creation of a synthesis that incorporates both old and new values through use of technologies both computer and human (15).

Dr. Huang is assistant director and Dr. Alessi is derector of the psychiatric informatics program in the department of psychiatry at the University of Michigan. 1500 East Medical Center Drive, Box 0390, Ann Harbor, Michigan 48109-0390 (e-mail, [email protected]). Dr Alessi is also director of the child and adolescent psychiatry program in the department. John H. Greist, M.D., is editor of this column.