Electronic Medical Records in Therapy

We all know that electronic medical records are the wave of the future. The very near future. In fact, the wave is washing over me as I write this! The outpatient clinic where I do some fee-for-service transitioned this week from paper progress notes to computerized ones.

The change was accompanied by the usual technological glitches (I didn't have access to the drives when I got there, which was a definite issue!), and special trainings for those unfamiliar with the new format. Some of my colleagues have been resistant to the whole idea, but in general, I'm like the idea of going electronic. For one thing, all that writing takes a toll on my hand! I'm especially looking forward to being able to cut and paste things that are the same each time, but I've had to write out again and again anyway. It's also more convenient to reference past notes, assessments, and treatment plans, and makes it much easier to find out what other providers (e.g., prescribers) are doing with a client (not to mention being able to read what others have written!).

That said, there are also some drawbacks. For one thing, most clients are fairly comfortable with the idea of therapists writing during a session. Typing is another thing altogether. We're slowly getting used to medical doctors using a computer during consultations, but many people still feel like the computer distances patient from provider, or even complain that doctors don't seem to be listening (because they're looking at a screen). Since such a crucial part of therapy is feeling heard, anything that interferes with feeling heard is a problem.

Even if we position the computer strategically and touch-type so that we can maintain eye contact while making notes, we still have to think about the sound typing makes, and what effect that might have on the client. Hand-writing can be pretty unobtrusive - someone who is engaged in affective processing is probably not paying much attention to whether or what I'm writing. However, if I'm typing, it's clear when I am - and am not - writing. My prediction is that more clients would wind up wondering what I was writing as they began to notice the timing of writing - and to engage in projection and possibly transference about it.

From these reflections, it seems clear that typing notes (at least during sessions) would result in some changes in the feel of the session. The obvious solution, of course, is to NOT type notes during sessions, but do it after. That sounds like a great plan - but it assumes the luxury of 50 minute hours, with that ten minutes at the end for mundane things like paperwork. I don't know about you, but I don't live in a world of 50 minute hours. I live in the world of 45 minute back-to-back sessions before I have to run out the door to make it to my other job on time. Everyone I know who isn't in private practice has to think about productivity, and would have to do any paperwork that doesn't get done during the session on their own time.

So what's the solution? I don't really know. Better pay for lower productivity? We can only dream. Clients resigning themselves to typing during their sessions? I fear that's more likely. What do you think about how electronic medical records will or should be integrated into mental health treatment?