Letters Review Resident Data Belore Computer Entry SIR: We read with interest the report of Zak et al. from South Florida on the pilot use of a palmtop computer to compile a residency log (Academic Psychiatry 1993; 17:143-148). Despite the finding that compliance was better with access to computer entry than with paper logs, our experience with resident/ fellow data collection suggests potential problems with any data collection system not subject to review. The residents and fellows on our consultation service record patient demographie, diagnostic, and treatment information on a scannable form that is entered into a computerized data base (1). This data is used to generate residency logs and for other clinical and administrative purposes. All forms along with a copy of the consultation note are reviewed by a senior attending physician prior to scanning and returned to the resident/fellow for correction of omitted or incorrect data. A systematic review of all forms over a 10-month period found that 50% of forms had at least one or more errors/omissions (2). Despite changes in the format of the form and attention to training in uses of the form, a recent brief survey found that a substantial number (53%) still require rereview. These errors occur despite our data recording ta king place within days after completion of the consultation. With the majority (94%) of the South Florida residents studied entering palmtop data weekly or less often, the possibility of error may be increased. Our experience leads us to urge caution in the use of any computerized data that is not subjected to review for completeness and reliability. Mary Allee O'Dowd, M.D. F. Patrick McKegney, M.D. Montefiore Medical Center Albert Einstein College of Medicine Bronx,NY I" '

References 1. McKegney FP, Schwartz CE, O'Dowd MA, et al: The development of an optically scanned consultation1iaison data hase. Gen Hosp Psychiatry 1990; 12:71-

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2. O'Dowd MA,McKegney FP: The (ab)useofcomputers (letter). AmJ Psychiatry 1992; 149:1117

In Reply SIR: Accuracy of data is very important when compiling any data base as Drs. O'Dowd and McKegney point out Throughout any data collection process, there are several types of errors that can occur whether the procedure is automated or not. Our article, "Palmtop Computer Residency Log" (1), was a report on a pilot study to determine the feasibility of using the palmtop to generate data for a resident's log. Our initial concern was to determine how the palmtop would perform: how user friendly, how useful the data might be, and at what cost. Our department did determine that the palmtop system was a viable approach, and we now use the system department-wide with each resident being assigned a palmtop. Over the past 3 years, we have refined several aspects of the process, including data entry, scheduled downloading, modification of database fields, and redesigning of reports, all in an effort to improve accuracy and compliance. Our review of data accuracy is integrated with the supervision process and using the power of the software program to generate error reports for some simple types of errors (e.g., exceeding field size, nondate data in date fields, etc.). We agree with Drs. O'Dowd and McKegney that accuracy of data input is crucial, and we join them in cautioning our colleagues on this issue. Jack Zak, M.D. Department of Psychiatry and Behavioral Medicine \ ( )I I \ 11 I ~ • ,,[ \ 11; 1 !, ' • I \ 1 I '", I

University of South Florida College of Medicine Tarnpa,FL References 1. Zak J, Harnett SK, Roth P, et al: Palmtop computer residency log. Academic Psychiatry 1993; 17:143-

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The Moral Myopia 0/ Academia and uThe Big Chili" 0/ Managed Care SIR: Jarnes E. Sabin (1) discusses the "moral myopia" of academic psychiatry in relationship to the educational challenges posed by managed care. He is right in pointing out the serious problems we will have to face in the future. While reading his artic1e and rereading the "Big ChilI" artic1e (2), several questions came to mind: First, Dr. Sabin defines ethical managed care as "a form of popuIation-based practice" that "seeks to allocate limited resources to achieve maximum utility." I believe that the expressions "population-based practice" and "allocation of limited resources to achieve maximum utility" are explaining the term managed care but not the term ethical. To my understanding the word ethical means conforming to some moral standards or conforming to some standards of a group or profession. I arn not sure if managed care has anything to do with moral standards or with the standards of our profession. I wouId like to ask Dr. Sabin for a more specific definition of the term ethical managed care. Second, Dr. Sabin states that the managed care clinician's concern is not only with current patients, but also with future patients. No matter how accurate this statement is, it might be quite difficult to explain to a current patient during the last allocated session. This issue seems related to another term in Dr. Sabin's article that deserves more explanation: the optimal well-being 0/ society. I am not sure what the optimal well-being of \( \llf\ll( 1'-,'\\ III \lln

societyisand whodefinesit. Ihope Dr. Sabin can further describe "the optimal wellbeing" of our society and how it can be achieved when resources are limited and nearly 50% of respondents in the National Comorbidity Survey reported at least one lifetime DSM-III-R psychiatrie disorder (3). Richard Balon, M.D. DepartmentofPsychiatry Wayne State University School of Medicine Detroit, MI

References 1. Sabin JE: The moral myopia of academic psychiatry: a response to Gien O. Gabbard's "The Big Chili." Academic Psychiatry 1993; 17:175-179 2. Gabbard GO: The big chili: the transition from residency to managed care nightrnare. Academic Psychiatry 1992; 16:119-126 3. Kessler RC, McGonagle KA, Zhao S, et al: Lifetime and 12-month prevalence of DSM-ID-R psychiatric disorders in the United States. Arch Gen Psychiatry 1994; 51:S-19

SIR: We read with interest "The Moral Myopia of Academic Psychiatry" (1), in which the collaborative relationship between Oregon Health Sciences University (OHSU) and Northwest Kaiser-Permanente was cited as a model for managed care-academic cooperation. Unfortunately, we must report that the inpatient portion of our collaboration no longer exists. In 1992, the university's hospital administration, the department of psychiatry, and Kaiser-Permanente all expressed dissatisfaction with the arrangement-but for different reasons. The university's hospital indicated that reimbursement from Kaiser for inpatient beds was below what was required to break even. Kaiser-Permanente indicated that the cost of care for each admission was higher at OHSU than elsewhere primarily due to a longer length of stay. The department of psychiatry was dissatisfied because some of the Kaiser physicians were unavailable to teach and none couId provide full attending coverage. ,,'