Current Technologies for Behavioral Healthcare Clinical Practice 2 John S. Luo Introduction In today’s electronic era, the thought of using only paper in clinical practice is not very high on the behavioral healthcare practitioner’s list of ways to be efficient and modern. However, paper has its use for taking notes during sessions as it lends itself more naturally to maintaining eye contact and has less distraction without the clicking noise of the key- board. Computers today offer many compelling reasons to be utilized in the office setting with easier access to information, transmission of data, and storage. For many practitio- ners, computer use has primarily been focused on electronic communication, marketing with a web site, or creation of documents with office productivity suites. This chapter reviews some of the computer hardware and software that will enhance clinical practice in this digital age. Hardware Some would argue that the age-old issue of Mac vs. PC still exists. Nowadays, it is a matter of preference to determine which operating system rules the office. In the past, Mac operat- ing system computers were considered for personal and educational use and for use in creative professions, whereas PCs were the dominant force in traditional businesses. With increasing Apple market share in all types of business, especially as the ease of use and increased availability of relevant Mac operating system (OS) software for business has developed over the years, trying to decide between Windows vs. Mac OS is a moot issue. In fact, as more applications are being developed for web delivery such as electronic medi- cal records, even a computer based on Linux OS has its place in the behavioral healthcare office. Today, the more challenging question is to consider a desktop computer vs. laptop. J.S. Luo UCLA Semel Institute for Neuroscience and Human Behavior, Department of Psychiatry, 760 Westwood Plaza, Los Angeles, California 90024, USA e-mail: [email protected] N.A. Dewan et al. (eds.), Information Technology Essentials for Behavioral Health Clinicians, 11 DOI: 10.1007/978-1-84996-344-2_2, © Springer-Verlag London Limited 2011 12 J.S. Luo Desktop Vs. Laptop The advantages of desktop computers are quite obvious in terms of higher performance for less cost. Large screens provide ample real estate to view multiple windows to facili- tate looking at various aspects of an electronic health record, or to be able to send e-mail replies while reading lab results. The standard computing power available today in both laptops and desktops far exceeds the needs of most behavioral health practices unless viewing magnetic resonance imaging (MRI) from a picture and archiving system (PACS) is a must. Utilizing a computer during a patient encounter such as clicking on checklists to docu- ment can be distracting and potentially takes away from the mindfulness of being with the patient. The frequent need to shift eye contact from patient to computer screen creates a frame that documentation, not the patient, is more important. Even tablet computers, which can mimic the process of taking notes on paper, can alter the delicate patient-provider frame. In behavioral health, establishing rapport in the first encounter is critical, so that the patient feels able to confide in and trust the provider. The patient can fill out an intake form in advance of the visit, which allows the face-to-face time with the patient to validate and clarify this information. If a computer is going to be used directly in the encounter to cap- ture information, it is important to ensure that it does not distract from establishing rapport. In contrast, using the computer during the patient encounter to demonstrate their progress, such as a chart demonstrating an improved Beck Depression rating over time or even showing their labs online does not distract from the encounter, but engages the patient and fosters that sense of connection. Once the need to illustrate a data point is over, the encoun- ter should return to the traditional face-to-face discussion. Placement of desktop computers next to patients at the bedside in the hospital has been established as an important factor in establishing quality of care and patient satisfaction1. However, in the office setting, studies have shown that communication patterns of provid- ers using an electronic medical record (EMR) vs. paper were not significantly different; however, providers using an EMR spent more time clarifying and ensuring completeness of information, and initial visits using the EMR took longer, on average, 37%, than using paper2. In behavioral health, placement of the computer is important such that it supple- ments the encounter frame and does not create a barrier. In this scenario, laptop computers and especially tablet computers have the clear advantage over desktop computers since they are less intrusive in the office setting. Another obvious advantage of a laptop computer is its ease of transport. If the practice has several locations, it may be the best method to assure that records are available unless an online-based electronic health record is used. One problem with laptop computers is what to do when the hard drive fails. Regular backup is essential to avoid loss of data; however, laptop computers rarely have a redundant array of inexpensive disks (RAID) setup, whereas with desktop computers, this feature is much easier to arrange. In a RAID setup, there are two hard drives where one drive is constantly mirroring the other. In the event that one of the hard drives fails, the other drive can take over, decreasing downtime as well as having a direct backup. Laptop computers therefore can best manage their backup with an Internet or local network drive-based backup system that continuously backs up critical files in the background. 2 Current Technologies for Behavioral Healthcare Clinical Practice 13 Internet Security With regards to Internet access in the office, there is continual significant debate whether wired or wireless is preferable. The advantage of standard wired Internet access is that there is a physical barrier towards access of the computer network system. However, this system is still vulnerable to hackers on the Internet who may be using various programs such as viruses and “trojan horse” to gain access to computers with potentially useful information for sale. Wireless networks such as 802.11b and 802.11n are certainly vulner- able to access attack by savvy computer hackers using software such as AirSnort, which enables them to crack the encryption key on the wireless network for access3. With the pressures of security mandated in HIPAA, one can imagine then that a standalone com- puter without any Internet access would be best for security; however, there is a significant price to be paid with regards to losing the convenience of finding information online, elec- tronic claim transmission, accessing an online EMR system, and sending prescriptions electronically. The best way to avoid intruder access to a wireless network is to use a media access control (MAC) address filter on the wireless access point and router4. In this setup, the router has a list of known computers, each with a unique MAC address, that have been authorized to access the wireless network. Whenever a wireless computer or device attempts to connect to the network, the router checks and grants access only to those devices whose MAC address has permission. In addition, a firewall on the network helps keep intruders out. Much like its traditional counterpart, which keeps flames at bay, a computer firewall keeps intruders out from access to a computer inside a network. In the past, a specific computer was given the task to run the specialized firewall software; how- ever, today, this function is built into the router, which provides Internet access that is shared across multiple computers. The firewall is preconfigured to keep external users on the Internet from accessing computers on the internal or office network. It blocks certain ‘ports’ which are like roads into the network but keeps some roads open for applications such as a web browser to operate. Whenever a computer program has trouble accessing the Internet, it is likely that the firewall has to be reconfigured to permit access. Another way to limit access to a wireless network is make it hidden. This privacy is accomplished by setting the service set identifier (SSID) or network name to not be broadcast, so that any computer searching for the network will not discover it. Therefore, only users who know of its existence can discover and gain access. More significantly, use a difficult to figure out security key (known as the wired equivalent privacy or WEP, Wi-Fi protected access or WPA, or WPA2 key) for access. It is highly recommended that the default key is changed, and that the new key is not too simplistic. Although it sounds like all of the above recommendations are difficult to implement, many of these configurations are now- adays conducted via the web browser access to the settings of the router. It is far less a headache to setup security properly at the onset than to discover later that a breach has been made. Once the setup is done, it does not have to change unless new computers or devices are added. Antivirus and antispyware/Malware programs such as Norton Anti-Virus5, Sophos Anti-Virus6, Spybot Search and Destroy7, and Malware bytes Anti-Malware8 or similar programs are important for maintaining computer health and function with the hazards 14 J.S. Luo encountered via the Internet. Once installed, these programs check e-mail and file down- load for viruses, malware, and Trojan software that can hijack your computer for informa- tion or to convert it into a “zombie” that will carry out the instructions from the hacker such as making multiple requests of a computer server to force it into a crash.