It’s hard to explain exactly what Google Wave is, but I like Google’s description that it’s “what email might look like if we invented it today.” To me, it’s email, blog, instant messenger, Facebook, wiki and Skype, all rolled into one thing.

Google bills Wave as a “personal communication and collaboration tool.” A “Wave” is like a shared email/web page that people who need to work together on something to use to communicate, to share images and files, to chat, and build a document collaboratively.

I don’t really want to go through all the features here, but I can see two really fabulous uses for Wave in telepsychiatry.

Telepsychiatry is mostly real-time, but, like most doctors these days, I’ve also got several email threads going with patients every day. I prefer to handle routine stuff like “can I change my appointment?” and “I’m confused about the CBT homework you gave me last week” via email. A private Wave with me and the patient as participants would be a wonderful record of things that are scattered over several emails right now. I could also think of ways to incorporate homework and rating scales and other things into a wave.

A more exciting use would be for the patient to control the wave and add or subtract providers onto a personal “medical wave.” The idea would be that I as a patient, for example, could grant access to my personal “medical wave” and that would facilitate communication between different caregivers really easily. The other is that my personal medical wave could, in some sense, be my portable medical record. It wouldn’t be hard, even now, to put in pdfs of labs, consults, etc, and just have this data be available to anyone who takes care of me in the future.

Really, there are two things that are stopping me from starting to experiment with Wave right now. First, the program is still in the alpha stage, and probably needs to mature a bit to get stable. The second is security. I like Google a lot, but would really like it if there were a wave server out there that was hardened to the security needed to manage medical information. Right now, Google’s got the only wave servers out there, but they claim they will make the specifications public in the future.

Somebody’s going to start a medical wave server company and that just might be part of the breakthrough in medical records that everyone is looking for these days.

In reply, another meeting attendee said: “Why don’t we just put video cameras in the unit, record all the time, and just let the insurance companies drown in the data.” He was, of course, being facetious, but I and others understood exactly what he was trying to say. Much of modern medicine (and, I would argue, most of it in some institutions) consists of “treating the chart” for legal and payment purposes rather than treating the patient.

I recalled this interchange while reading a great pair of books recently: Total Recall: How the E-Memory Revolution Will Change Everything by Gordon Bell and Jim Gemmell and Delete: The Virtue of Forgetting in the Digital Age by Viktor Mayer-Schonberger. You can pretty much guess the topic of the books from their titles, and the authors’ viewpoints on these topics. Bell and Gemmell are taken by just how data about our lives can be collected and stored, even with current technology, while Mayer-Schonberger is carefully warning us to be careful about what we save. Both books are well thought out and carefully written. The authors of the first book are not Pollyannas, the author of the second is not a Luddite. All the authors have thought carefully about how the future will look like in a world with ubiquitous webcams and in which every email, text message, photograph we take and our physical location can be captured and recorded digitally with no intervention on our part required. I recommend both books highly, and it’s definitely fun to read one after the other.

I know there are multiple applications for recording Skype calls, so I know that I could potentially record all my Skype sessions with patients digitally and preserve them. My yet-to-be-approved informed consent form for telepsychiatry explicitly forbids me or the patient from making recordings of our sessions. However, I think the decision to go this way is not a simple knee jerk “patients need privacy so that’s that,” but has some real pluses and minuses that merit some serious discussion, just like the books I’ve been reading.

In my next post, I’m going to blog about the problem of whether interactions between patients and doctors should be recorded. My prediction is that now is not the right time, but that recordings will become part of the standard of care in just a few years.

If you just have paper records, then this issue isn’t problematic-—you use the computer monitor for Skype, and your regular paper notes. However, my record keeping system is on line, and I need to get to it via my browser. (I use dokuwiki, free wiki software that runs on a server at my home. I keep a daily journal on the wiki of patient encounters and each patient has his or her own wiki page. When the patient comes in, I just put a date at the top of his or her wiki page and write my note. Very simple. Very easy to maintain. Every edit is logged and every previous version is kept. This plus nationalerx.com = free online EMR system that works very well for me. Setup time for dokuwiki for someone who knows how to manage a webserver and understands PHP: 10 minutes.)

The obvious way to solve the problem would be to devote half the screen to Skype and the other half to the browser. In Windows, the easy way to do that would be to tile the windows next to each other and go to work. Unfortunately, Skype doesn’t conform to Windows standards and allow you to resize the window are using, so the tiling commands in the operating system don’t help. I haven’t found an alternative to manually sizing the windows and placing them myself, which wastes a minute or so of my time doing something that should work in a second.

Although I wonder if this flaw in Skype has something to do with DirectX, it still seems that it wouldn’t be too much trouble to fix. Obviously, the Skype window, like any other, needs to be a certain size to be useful. On the other hand, it wouldn’t seem to be much more than a few lines of code to make Skype into a good Windows citizen.