What “Meaningful Use” of Electronic Health Records May Mean to Psychiatrists

With billions of dollars for electronic health record (EHR) technology purchases hanging in the balance, psychiatrists need to be paying attention to the Department of Health and Human Services (HHS) deliberations on the definition of “meaningful use.” HHS Secretary Kathleen Sebelius is supposed to set an interim definition in a few months. This is important to all office-based physicians because it will set the requirements they will have to meet for proving they are making meaningful use of EHR software and hardware they previously purchased. If they can make the case, starting in 2011, they would qualify for federal grants to partially compensate them for those previous software and hardware purchases.

Those grants are available for 5 years, and if obtained starting in 2011, they could amount to as much as $64,000 per practice for psychiatrists whose patient mix is at least 30% Medicaid recipients. That figure falls to $44,000 for physicians who cannot meet the Medicaid percentage and who see Medicare patients, with no specific percentage of the latter being designated.

There is also a penalty for physicians who do not meet the meaningful use definition. It comes into play after 2016; the Medicare fee schedule for professional services is reduced by 1% in 2015, by 2% in 2016, by 3% for 2017, and by between 3% to 5% in subsequent years.

The grants were authorized by the American Recovery and Reinvestment Act (ARRA)—which is the stimulus bill Congress passed last winter. Sebelius will set interim requirements based on recommendations from 2 new advisory committees that were established by the ARRA: a health information technology policy and a standards committee. The meaningful use requirements will be different, in part, for office-based physicians and hospitals, but they will have escalating requirements in 2011, 2013, and 2015.

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Off-Label Prescribing

Medications cannot be marketed in the United States without an FDA determination that they are safe and effective for their intended use. To obtain such certification, pharmaceutical companies submit their products to rigorous scrutiny (eg, in vitro studies, animal studies, human clinical trials) and present the subsequent data to the FDA, which determines whether the medication in question is safe and effective for a specific purpose. FDA approval comes with specific labeling requirements for the product, including the approved indications for use, the appropriate dosing, and the specific populations for its use. Once a medication has been approved for a specific use, physicians and other prescribers are permitted to prescribe the medication for conditions not covered by the approved use.

Several recent studies have dem­onstrated that off-label prescribing is very common among physicians, particularly among psychiatrists. Legal scholars have estimated that approximately 40% to 60% of prescriptions are for off-label use.1 In one important study, researchers examined office-based prescribing patterns for 160 commonly prescribed medications and determined that approximately 21% were for off-label use. In this study, off-label use was most common for cardiac medications (46%), anticonvulsant medications (46%), and asthma medications (42%). The investigators also found that most off-label use (73%) had limited or no scientific support.

The greatest disparity in the percentage of scientifically supported versus unsupported off-label use occurred with psychiatric medications. In 96%, the off-label use was determined to have little or no sound scientific evidence for the condition for which the drug was prescribed.2

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Psychiatrists may cut some ties to drug firms

Dr. Daniel Carlat knows all too well how easy it is for doctors to be seduced by drug industry money.

In 2002, he earned $30,000 in speaking fees to promote Wyeth's antidepressant Effexor XR to fellow doctors.

"I quit doing it because I felt I was beginning to push some ethical boundaries in terms of what I was saying and what I was not saying," said Carlat, a psychiatry professor at Tufts University in Boston who believes doctors need to cut their financial ties with drug companies.

"My own story was really nothing special," he said in a telephone interview. "I made $30,000 for the year, which is less than some of these doctors make in a weekend."

Carlat and other psychiatrists have been studying the issue and have proposed that the American Psychiatric Association cut back on medical education seminars funded by drug companies.

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Psychiatric manual's update needs openness, not secrecy, critics say Edition is being prepared with strict oversight, officials counter

Whether revisions to the "bible" of mental illness should be carried out in secret might seem like an academic question.

But the issue carries real weight for parents desperate to address children's difficult behavior or people in distress over their mental state. It also speaks to citizens' concerns over news accounts of an overmedicated America and the troubling financial links between the pharmaceutical industry and some psychiatric researchers.

An update is under way for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, known as the DSM, which defines the emotional problems for which doctors prescribe drugs and insurance companies pay the bills. Psychiatrists working on the new manual were required to sign a strict confidentiality agreement.

Critics say the American Psychiatric Association should lift the curtain of secrecy so outside observers can review the scientific debate behind new and revised diagnoses.

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Johnson & Johnson Psychiatric Gifts Probed by Senate (Update2)

Johnson & Johnson, the world's largest health-care company, said a U.S. Senate committee probing payments to doctors by drug and medical-device makers has asked about company support of psychiatric professional groups.

J&J, of New Brunswick, New Jersey, is responding to the request, received Oct. 23 from the Senate Committee on Finance, the company said today in a regulatory filing. The letter asks about ``any payments or benefits to a number of specified psychiatrists associated with psychiatric professional associations or otherwise authorities in their field.''

Committee members Charles Grassley, an Iowa Republican, and Herb Kohl, a Wisconsin Democrat, sent a similar request Oct. 16 to J&J, Medtronic Inc. and Abbott Laboratories about support for a medical-device conference. Grassley has also said he is probing payments by AstraZeneca Plc and Eli Lilly & Co. to psychiatrists and disclosures by Stanford University professor Alan Schatzberg, president-elect of the American Psychiatric Association.

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Long-term psychotherapy is superior, study finds

Psychotherapy lasting for at least one year is more effective than shorter periods of therapy for people with complex mental disorders, such as personality and chronic disorders, according to a study published today in the Journal of the American Medical Assn. The success of dedicated psychotherapy may matter little, however, because fewer doctors are offering the service and fewer insurers are covering it.

In long-term psychodynamic psychotherapy, the therapist provides continued, close support for the patient while the pair work through problems and interventions. The JAMA study, from researchers in Germany, was an examination of 23 studies on the success of psychotherapy. It found that longer-term therapy (one year or longer) was superior to shorter-term methods in regard to overall outcome and personality functioning. On average, patients with complex mental conditions who were treated long-term were better off than 96% of the patients in the comparison groups.

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Army Use of Psychiatrists in Interrogations Called Unethical

U.S. military psychiatrists may be asked to assist in interrogations of detainees, in apparent conflict with American Psychiatric Association and American Medical Association policies, said a researcher here.

In 2006, both associations endorsed policy statements forbidding psychiatrists and other physicians from being present at interrogations or advising on techniques to be used on individual detainees. (See: APA: Stay Out Of Interrogations, Psychiatrists Urged and AMA: Prisoner Interrogation Unethical for Physicians, Declares AMA Panel)

"Yet documents recently provided to me by the U.S. Army in response to requests under the Freedom of Information Act make clear that the Department of Defense still wants doctors to be involved and continues to resist the positions taken by medicine's professional associations," wrote Jonathan H. Marks, M.A., B.C.L., of Penn State University, in the Sept. 11 issue of the New England Journal of Medicine.

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Psychiatrists Prescribing More Drugs, But Not Psychotherapy

A declining number of office-based psychiatrists appear to be providing psychotherapy to their patients, according to a report in the August issue of Archives of General Psychiatry.

Psychotherapy has been part of the practice of psychiatry for generations. "Yet, despite the traditional prominence of psychotherapy in psychiatric practice and training, there are indications of a recent decline in the provision of psychotherapy by US psychiatrists -- a trend attributed to reimbursement policies favouring brief medication management visits rather than psychotherapy and the introduction of newer psychotropic medications with fewer adverse effects," the authors wrote.

Ramin Mojtabai, MD, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, and Mark Olfson, MD, Columbia University Medical Center and New York State Psychiatric Institute, New York, New York, analysed trends in psychotherapy provision using data from national surveys of office-based psychiatrist visits from 1996 through 2005.

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Psychiatric Group Faces Scrutiny Over Drug Industry Ties

It seemed an ideal marriage, a scientific partnership that would attack mental illness from all sides. Psychiatrists would bring to the union their expertise and clinical experience, drug makers would provide their products and the money to run rigorous studies, and patients would get better medications, faster.

But now the profession itself is under attack in Congress, accused of allowing this relationship to become too cozy. After a series of stinging investigations of individual doctors’ arrangements with drug makers, Senator Charles E. Grassley, Republican of Iowa, is demanding that the American Psychiatric Association, the field’s premier professional organization, give an accounting of its financing.

The association is the voice of establishment psychiatry, publishing the field’s major journals and its standard diagnostic manual.

“I have come to understand that money from the pharmaceutical industry can shape the practices of nonprofit organizations that purport to be independent in their viewpoints and actions,” Mr. Grassley said Thursday in a letter to the association.

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With Precautions, Psychiatrists Need Not Shun off-Label Prescribing

Fear of lawsuits should not stop psychiatrists from prescribing medications for off-label indications as long as they make patient-centered decisions based on evidence and talk to patients about risks and benefits.

By focusing on patient care and providing appropriate informed consent, consultation-liaison psychiatrists can protect themselves from liability lawsuits regarding the use of antipsychotics and other medications for indications not approved by the Food and Drug Administratio (FDA). So said experts who led a workshop for consultation-liaison (C-L) psychiatrists at APA's 2008 annual meeting in Washington, D.C., in May.

Off-label use includes prescribing medications not only for unapproved indications, but also for unapproved dosages and patient populations, some of which may be subject to specific warnings by the FDA, said Ramaswamy Viswanathan, M.D. He is the director of the C-L Psychiatry Department at the State University of New York Downstate Medical Center in Brooklyn, N.Y. Intravenous infusion of haloperidol and the use of antipsychotics to treat dementia-related agitation are only two notable examples.

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Psychiatrists Top in Drug Maker Gifts

As states begin to require drug companies disclose their payments to doctors for lectures and other services, a pattern has emerged: psychiatrists earn more money from drug makers than doctors in any other specialty.

How this money may be influencing psychiatrists and other doctors has become one of the most contentious issues in health care. For instance, the more psychiatrists have earned from drug makers, the more they have prescribed a new class of powerful medicines known as atypical antipsychotics to children, for whom the drugs are especially risky and mostly unapproved.

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Objective Monitoring of Schizophrenic Patients Doesn't Measure Up

Psychiatrists need to do more objective measurement of the physical and mental health of their schizophrenic patients, researchers said here.Psychiatrists have been relying on clinical judgment, doing minimal medical record-keeping, and sometimes haphazard monitoring of physical consequences of antipsychotic medication for schizophrenic patients, according to a panel of speakers at an industry-funded satellite symposium here held in conjunction with the American Psychiatric Association.

That needs to change, both for the health of patients and to get ahead of pay-for-performance trends, said John M. Kane, M.D., of the Albert Einstein College of Medicine in New York.

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