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Psychiatry in the Digital Age
by Milton P. Huang, M.D., and Norman Alessi, M.D.
1997

The advance of technology has a pervasive influence. People talk of a "digital age" or the "information revolution" changing society itself. The impact of information technology will bring change to both the face and the heart of psychiatry, ranging from how we practice to how we think. In exploring how these technologies will affect psychiatry's future, we must move in broad sweeps, looking first to the overt changes in technology itself, then to more profound questions, such as who will use it, and how will this use alter psychiatric practice?

Welcome to the Digital Age

In the past, communications used analog technologies in which speech or video was translated and sent on waves from one point to another. Digital technologies, using discrete bits of data, were limited to characters on a teletype or keypunch. Now, computers can process digital signals at phenomenal rates, and all information is being digitized. Old cassette tapes and records have made way for digital tapes and compact discs. Sound and video are digitally compressed and sent through the Internet. Computers are no longer restricted to managing simple punch tapes, but now store, process and distribute all types of information at higher, faster rates. Computers are becoming a larger part of all our communication activities.

Much of this digital trend is derived from the exponential growth of computer processing power. Each year, computer chips are manufactured that can store more information and process it faster. This tendency has even been informally codified as Moore's Law, which states that the capacity of computational devices doubles every 18 months. This growth is expected to continue, driving an increase in communications speed and in the potential abilities of computer-based information tools.

These trends are bringing us to a future of ubiquitous computing. Computers will become an integrated part of our lives, present everywhere. Already, computer chips process information in our car engines, our thermostats and many everyday appliances. These isolated information processors will soon communicate with each other. Car engines already exist that send signals to the manufacturer about potential problems, inefficiencies or breakdowns. There will be more and more computer-based tools that send or process information. We will expect them to be available at our fingertips to monitor and store information. We will expect them to be easy and intuitive to use in achieving different information tasks. We will expect these new tools to serve us and our communications needs as well as or better than our current tools.

Despite such expectations, anyone experienced in dealing with computers knows that they often fail to meet our anticipations. In large part, this is because computers lack the incredible abilities of abstraction that people take for granted. Computers are concrete devices that require sameness and clear definitions. For this reason, one of the greatest hurdles facing the use of computers is defining standards so that different computers can work together. The development of a communication standard for the Internet as part of the World Wide Web project resulted in an explosion of Internet use over the past few years.

The great press of growth of computers and computer applications is creating a rush of new standards that attempt to take advantage of new technology. Not all will survive. Sony's BetaMax format for video recording was a standard that disappeared when displaced by the cheaper VHS tape format now used in all VCRs. Companies pushing videodisc technologies are now trying to displace the VHS standard by putting more movies on videodiscs and aggressively selling machines. In a similar way, the Internet has become a battleground as competing companies attempt to create new communication standards to add sound, animation and video to standard Web documents. Different web "browsers" display the same Web document differently, depending on the manufacturer. In the end, this results in much confusion as users do not know what to purchase. They become frustrated when they obtain software that does not interface with everyone else's, or worse, becomes obsolete. We must anticipate that the future of technology will be one of continued advance, yet also one filled with difficulties caused by the competition of new standards and the extinction of the old. The ultimate driving force in determining what survives and what will develop is what is used. An examination of the users of technology will shed light on how that technology is used.

The Users of Technology

At first glance, it seems that one can simply point to particular individuals and say, "So-and-so is a geek. He or she will the be the first to use or create anything new with computers." Yet, it is more useful to take a broader look at the question of who uses technology. There are specific groups that will drive the future use of information technology because of their goals and need to employ more advanced information transfer to achieve those goals. We will look at four categories of important users: researchers, commercial information providers, commercial health care providers and the individual health care provider.

Researchers

Researchers and academicians deal directly with the business of knowledge and were the first groups to employ information technology and shape its future. They need rapid access to bodies of published journals and previous research. They need the ability to communicate with colleagues and publish their ideas and findings. Such needs have lead to the development of extensive electronic data bases like MEDLINE. Supported by the National Library of Medicine, this data base contains about 7.8 million records with 31,000 new citations added each month. Paralleling this increased access to information is the creation of electronic publications and pre-print services where scientists can more quickly publish and disseminate information outside of traditional review structures. In many fields, it is becoming essential to be on-line in order to contribute and learn from research advances. The Internet is beginning to serve as a general information repository for scientific and medical knowledge.

Commercial Information Providers

As researchers continue to build an electronic repository of scientific information, commercial interests will find ways to exploit this trend. Information in electronic form is easier to compile, manipulate and distribute. This ease will encourage more and more groups to fill the role of repackaging information and selling it to different groups. Information that traditionally moved in scientific circles will be sold to the public on multimedia CD-ROM or through Internet subscription services. Public demand for information and willingness to pay for it will give rise to a wave of information provision companies, and these companies in turn will make it more profitable to generate electronically based information.

Commercial Health Care Providers

Commercial health care providers will also be motivated to increase the amount of electronically based information. Managed care organizations must have information in order to manage. They need to know how much services cost, which ones are effective and who provides them competently and efficiently. As researchers and commercial information providers develop more and more tools to create, edit and analyze research information electronically, managed care organizations will also seek to create, edit and analyze clinical information electronically. Already, some companies exist that simply monitor physicians or institutions by recording patient and treatment data, then analyzing the resultant data bases. They can determine the effectiveness and cost of particular procedures and interventions as well as provide a basis for comparison between physicians and other care providers. Because of the current demand for cost-efficiency in health care, there will be a call for the application of such tools and services, which will grow in use and sophistication.

In addition to using information technology to manage care, commercial health care providers will also use information technology to deliver care. Telephone answering banks or "dial-a-nurse" services are examples of simple information technology that such organizations are already using to manage and deliver health care. Other examples include computers that automatically call to follow-up patient visits with questionnaires or to remind them of appointments. More complex types of services are possible, including the use of video-based telemedicine. This type of service allows physicians to "visit" a patient where both see each other on a video screen. Such services are now offered to psychiatry patients in over 11 states, extending the physician's reach to rural locations hundreds of miles away.

Individual Health Care Providers

Just as commercial care providers will employ technology to reach more patients and provide more services, individual clinicians will also use these technologies for their daily tasks. E-mail, the World Wide Web and other communication technologies will help them keep in touch with recent research, colleagues and even patients. Some clinicians are already using the unique characteristics of e-mail to keep in contact with patients who need transitional-type reminders from their therapists. As the cost of using technology decreases and the ease of use increases, more and more of the information tools mentioned previously as being used by commercial providers will be available to help the individual clinician administer care.

The Future of Technology in Psychiatry

Given the existence of all of these groups which wish to use information technology, we see some inevitable trends which they will push forward, influencing both the surface and the depth of psychiatry. On the surface, the most powerful trend will be toward greater information generation and sharing. Researchers and health provider organizations will share a common goal of gathering data to monitor outcomes. Clinicians will be encouraged or required to add their cases to the data pool, whether to create knowledge about particular illnesses or to be reviewed in their standard of applying care. They will have to be "plugged in" to the network so they can both send information into research/management data bases and retrieve distilled summaries of the current treatment guidelines constructed from data base analysis of what is effective.

Although it can improve clinical care and patient satisfaction, such extensive data sharing is a double-edged sword that reduces patient confidentiality with increased use. There are examples of pharmaceutical companies that have compiled data bases of patient information to monitor the effectiveness of their products as well as send mailings out to potential customers based on their diagnosis. Although most people do not mind the technology that allows a computer to create an issue of Time magazine that has an advertisement targeted specifically at them with their name, one feels their privacy invaded when such technology is allowed to manipulate mental health information. The fact that the "plugged in" psychiatrist enters information into such data bases will change basic aspects of the doctor-patient relationship. As medical practice requires more focus on data and proper triage and treatment, the emphasis of medical work will shift from taking care of patients toward that of a clinician gathering information from patients, assessing patient information and providing information to patients. Such a trend is already augmented by current shifts to managed care and other large institutional care providers which want and use such information.

Even if we could remove the force of such institutional directions, these deeper and less overt effects of technology will also affect the individual relationship between patient and physician. Important questions arise as individual clinicians use information technology in administering care. Can the same degree of warmth be communicated through a videoconference connection? How do the reciprocal object relations change as the psychiatrist begins to see the patient less as a person and more as a data point in a managed care or government data base? Although "data" might seem an extreme description, this effect arises in a subtle fashion whenever anyone is expected to categorize or capture contact with a person within the constraints of what a computer can recognize.

Pandora's box has been opened and the ubiquitous influence of information technology will bring all these consequences. We cannot avoid it and should not. If we keep in mind a clear understanding of our goals and who we are as psychiatrists, we can employ these changes to our benefit. More advanced information technology will allow us to measure things we have not measured before, categorizing variables from facial expression to tone of voice. We will be able to correlate the incomprehensible quantities of data from genetic code to verbal self-expression to social and family interaction. We will be able to use new conceptual models that allow complexities impossible to describe in a single book. The digital age will bring turmoil as change is always difficult to deal with, yet as Pandora found, hope also lives in the opened box.

References

  1. Bennett J, Huang MP, Alessi N. Barriers to Telemedicine in Psychiatry. In: Miller M, Hammond K, Hile M, eds. Mental Health Computing. New York: Springer-Verlag; 1996.
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Dr. Huang is the first psychiatric informatics fellow of the University of Michigan and is responsible for WWW development of UM's Psychiatry Star. Dr. Alessi is chief information officer for the department of psychiatry at the University of Michigan and director of the child and adolescent psychiatry division.