Multimedia Reviews: Multimedia Convergence for Clinicians

This column provides a welcome opportunity to show how audio, visual, and print media and their various subtypes are converging in a variety of new applications and devices for clinicians. This phenomenon was first recognized by the former Psychiatric Society for Informatics, which has since changed its name to the American Association for Technology in Psychiatry (AATP) (www.tech psych.org). The former name was a reaction to earlier names for the group that included the word "computers." The group wanted to be seen as involved with something more than computers, which were thought to be dehumanizing and mindless and which might ultimately put psychiatrists out of their jobs—or so some believed. "Informatics" connoted epistemology, philosophy, and sophisticated uses of databases and other content rather than use of tools.

One technology that seemed quite distant from computers was telepsychiatry, in particular because it involved analog signals sent by telephone lines or by satellite. The American Psychiatric Association (APA) had separate committees on separate councils addressing the issue of telepsychiatry. However, the technology has converged, as anyone with a Webcam can attest. Now the tools have multiplied, and they come in many different packages. Encoding signals digitally has provided a way of recording images on DVDs, which can be done with computers.

Personal digital assistants (PDAs) and other handheld devices, such as cellular telephones, have also started to converge. Now one's cell phone can be one's camera, PDA, and more. For many years, voices were recorded in analog form, and dictation had to be taken from recordings. Use of digital encoding has led to increasingly efficient voice recognition software.

The main fear about computers now is loss of privacy rather than competition. We don't know how the privacy protections mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) will work out, but we do know about the abuses that led to their inclusion in the legislation. Physicians have come to feel more secure about software. One reason that the fear of competition is unfounded is that physicians remain in short supply. Even radiologists' jobs do not seem in trouble, despite the fact that images can now be stored digitally and can be read anywhere. No machine has been allowed to make medical decisions. Most psychiatric decisions turn on data not available to computers.

AATP's annual meeting is traditionally held the Saturday before APA's annual meeting. The 2003 AATP meeting in San Francisco featured several presentations that drew on different media. Jesse Wright demonstrated a DVD-ROM for computer-assisted cognitive therapy, the details of which have been published elsewhere (1). The article describes how to make DVDs with which patients can interact by using menus not unlike those in DVDs that are used recreationally. The initial financial investment, although significant, is much less than it was in the days of movie studios. DVDs bring together sound, images, computers, other technological features, and patient participation—all under the guidance of an experienced therapist. Therapists who create DVDs to help their patients understand and become engaged in treatment will have more time to focus on patients' individual needs, because they will be spared having to repeatedly describe the basic elements of treatment.

This technology is especially attractive in developing countries. Thyloth Murali of the National Institute for Mental Health and Neurosciences in Bangalore has used a similar technology combined with battery-driven laptop computers to bring the message of psychiatric rehabilitation to remote villages in India that do not have electricity (2).

At the AATP meeting, Stephen Cozza described the development of a clinical and business strategy for telemental health care. Costs for this multimedia activity have plummeted. The Federation of State Medical Licensing Boards, Medicare, and an increasing number of states allow reimbursement for video consultations. E-mail consultations based on text alone are not reimbursable. Thus the addition of moving visual images and real voices now permits the adequate practice of consultation medicine.

The domain of words encompasses many forms, including spoken and written forms, which have various modes of storage. At the meeting Colleen Crangle from ConverSpeech discussed the use of WordNet as a tool for consumer health information systems. She described a case study in which psychiatric information was sought. A visit to the ConverSpeech Web site (www.converspeech.com) shows that the purpose of WordNet is to extract data from a variety of verbal media: Web pages, electronic publications, e-mail messages, and word processing files. The software automatically identifies the key concepts in each document, determines which documents contain detailed information that matches the user's interest profile, and extracts key information from, summarizes, and categorizes documents.

Alex Green's presentation on the coming of age of speech recognition technology touched on Dragon, which already has a large base of physician users and is well known for its excellent medical vocabulary. He also spoke briefly about Pro-Med Medical Solutions; IBM ViaVoice, which also has an excellent medical vocabulary; and database-driven solutions, such as ChartLogic (Task Technologies) and Pacific Voice for Medicine (Medical Voice Products). The attraction of voice recognition technology is the ease with which the record can be stored electronically for editing and printing. Speakers no longer have to use robotlike pauses between words. Accreditation agencies object to boilerplate notes that emerge from checklists and menu-driven descriptions. Voice dictation enables a wide choice of words, and text can be individualized very well—almost too well, in that a common experience is the discovery that the use of longer words results in better recognition, improved spelling, and better grammar. "Four" could be "4" or "for," but "qualification" is always recognized as such. Those who prize short Anglo-Saxon words find themselves shifting to longer words, often derived from Latin. Voice recognition can be completely private, using handheld or desktop devices that are not constantly connected to the Web via a cable or DSL line. Such connections can permit data to be harvested without the user's knowledge. In addition, use of a transcription service is unnecessary, which further safeguards patient data.

Decision support software and computerized guidelines are also useful. The suggestions they generate may help clinicians check results of treatment vis-à-vis guidelines or reduce risk and liability. At the AATP meeting Ken Altschuler and Madhukar Trivedi demonstrated the Texas Medication Algorithm Project (3,4). This system can use a variety of media to input drug orders for review against treatment algorithms. Users do not perceive the system as coercive or as a Big Brother watching over them, because the many clinicians who participated in its development regard it as their own. One principle on which it is based is that any guideline that generates no exceptions is coercive, meaningless, or otherwise deficient. Algorithms help clinicians organize their thinking, confront decision points, and use evidence-based prescribing suggestions. The system is remarkable for having been widely adopted in Texas and elsewhere, even though it encountered the usual barriers to the acceptance and implementation of such guidelines.

New York State's Office of Mental Health has had a similarly successful experience using guidelines that address such areas as dosage, medication interactions, and use of multiple medications. Because the guidelines were developed for tertiary care hospitals, where a majority of patients have treatment-refractory illnesses, the number of exceptions that clinicians make in using the guidelines is necessarily higher. Drug utilization committees at hospitals where the guidelines are used are both questioning and supportive in the matter of exceptions. Years of data on a patient's use of medications have been collected for review by treating psychiatrists in simple, clear visual and text formats that save hours of reviewing old medication administration records or physicians' order sheets to determine what medications the patient has previously taken and whether the trial was adequate.

Clinicians seem to be much more accepting of guidelines, especially those that they perceive as having been developed by peers, such as the APA guidelines. Technology can make guidelines and other prescribing information immediately available and interactive. Clinicians recognize that in the long run such technological interventions improve patient care and protect patients and clinicians. In a review of the literature on several multimedia applications, Das (5) found that computers help psychiatrists by supporting decisions they have made or by suggesting alternatives.

At the AATP meeting, George Lundberg, former editor-in-chief of JAMA and editor-in-chief emeritus of Medscape/WebMD, brought everything together in his presentation, urging that use of the Internet for medical purposes not be a missed opportunity. He described uses—and some misuses—of the Internet for information and presented statistics showing that patients' use of the Internet is growing rapidly. Although the physician-patient relationship is affected when both parties are able to seek out new information together, the Internet is unlikely to substitute for medical education and judgment. However, some physicians are being left behind as their patients increasingly use the Internet. In fact, Dr. Lundberg suggested the Internet could be used eventually to make an individual health plan for every person in America—280 million of them. The Internet can reduce the costs of producing scientific journals. Multimedia publications on the Internet can shorten delays in publication. The Internet can combine text, audio, pictures, and moving images in real time. Anyone who wants a hard copy can print it out.

The afternoon was devoted to one of the AATP meeting's most popular features: John Luo's demonstration of the many uses of PDAs. These devices, unlike desktop computers, have been embraced by physicians, and some studies have shown that more than 40 percent of physicians carry them (6). Why? Computers, especially those that are constantly turned on and connected to the Internet, are a battleground between the user and individuals who sneak things in or out. Viruses are likely to continue to be a huge problem for users of Windows. It is hard to avoid leaving cookies wherever we go on the Internet. Sophisticated spyware can be implanted covertly. Spam has trashed the e-mail experience, but so far it is less of a problem for PDA users for a variety of reasons.

Physicians say they like PDAs for convenience and a greater sense of privacy and control. PDA versions of the Physicians' Desk Reference and other medication programs can help clinicians detect and prevent errors. So far no PDA viruses have been created. Physicians like the idea of having access to instant messaging, a telephone, and their schedule wherever they go. They can use the many wireless links that have sprung up all over to communicate with desktops and other PDAs.

Use of digital encoding for content now includes images—fixed and moving—as well as words and menu-driven applications. However, the number of devices that employ this common digital technology has multiplied because of the desire for using the new media devices and to enhance portability and convenience.