Are health professionals getting too much screen time? Computer‐driven care and its impacts on mental health practice

Since the advent of television, there has been concern about how “screen time” might affect the developing brains of children and contribute to health problems. Interacting with a device will inevitably change the brain and “how much” is “too much” is a question that preoccupies parents, educators and health professionals (Dickson et al., 2018; Gillespie, 2019). I invite health professionals to turn their gaze towards the provision of mental health care and consider how engagement with information systems may be impacting on their own development, view of mental health service provision and relationships with service users. I will focus on the Australian experience which may provide salutary lessons for other countries whose health services are not as far along the journey of becoming paperless and protocol-driven. Fifteen years ago, I wrote a paper decrying the imposition of “routine outcome measurement” on health professionals (Lakeman, 2004). An information system was introduced in Queensland which required all health professionals to enter a Health of the Nations Outcome Scale (HoNOS) and other data on every person they encountered and to account for how they spent every moment of their time. Quite aside from this one-size-fits-all approach being an anathema to recovery-focused individualized care, and no evidence that it actually improves outcomes for anyone, I was incensed that our small team had essentially lost a full-time equivalent position to administration. This paper was widely cited as an alternative viewpoint to the dominant discourse that measuring things improved quality and was inherently good, but the paper had no real impact. Australia arguably now leads the world in measuring things in mental health, although the quality of care remains questionable as numerous public inquiries attest. The Australian Mental Health and Outcomes Network (https://www.amhocn.org/) is well on its way to having every service provided in Australia classified, associated with a diagnosis and with standardized “outcome measures.” Routine outcome collection and benchmarking are extolled using language reflective of the zeitgeist of the times. For example, these things will “improve quality,” “map the journey of recovery,” “support the development of a therapeutic relationship” and “improve outcomes.” The only thing lacking in this impressive repository of information is any convincing evidence that collecting outcomes has or will lead to these outcomes. What is certain is that compliance increases the amount of screen time for clinicians and reduces the amount of time with patients. The State of Queensland now has a greatly expanded information system that is even more demanding of people's time and actually dictates what kind of care can or ought to be provided at any point in time. Now, a generation of health professionals knows no other system than one driven by computer protocols. The information system is not a mere medical record (a tool for clinicians), rather it directs clinicians to categorize service episodes, record diagnoses, record outcomes and incentivizes particular behaviours, e.g. “metabolic monitoring.” It is the primary lever which the central administration uses to shape the culture of practice. Today spending 30% of one's time with service users, which is about the benchmark for nurses (Haw & Kotterbova, 2016) is an aspiration for most clinicians and services. While the system ought to tell one how much actual time people spend with people, the “provisions of service” that people enter are widely regarded as works of fiction. When working in an emergency department any encounter with someone would take at least an hour to account for (usually much more). I would sometimes “catch myself” becoming impatient to get away and “get to work” on the computer rather than be with people, as giving the machine what it demanded was the “real work” that had to be done. The system is designed to shape clinician behaviour and does so in a profound way and leads to some absurd scenarios where the computer literally says “no.” For example, I once completed and documented an extensive assessment which I wanted on record for a young person and was told by an administrator “you can't do an assessment.” This was because unless the person had an “open service episode” with a specific team and I was a member of that team, no note could be written, and therefore, no assessment conducted. Ironically, this young person was assigned to me precisely because she was not willing or able to fit into the rigid models of continuing care that were otherwise offered and was thus a frequent presenter to the local emergency department. There is nothing inherently wrong with attempting to shape the behaviour of clinicians or encouraging people to follow protocols, but the amount of “screen time” will inevitably have an impact beyond mere compliance with the protocols. Long before the invention of the personal computer, Marshal McLuhan famously observed that “we shape our tools, and thereafter our tools shape us” (in Lakeman, 2008). Speculatively people's capacity to be fully present with people, be genuinely curious, “sit with” uncertainty or even have psychotherapeutic encounters with people may be undermined. These capabilities are not rewarded. Information systems have a voracious appetite for information. They demand definitive categorization of things like diagnosis, the reduction of experience to numbers and linear ways of operating. What is rewarded (giving the system what it wants) is reinforced. Following a protocol, completing an “outcome measure” or viewing someone's journey or problems through the lens of software can shape clinician's professional identity and capabilities. In much, the same way that too much screen time might be harmful to young people and impact on their development, so too might this be the case for clinicians.