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Sistema de Información Científica
Red de Revistas Científicas de América Latina y el Caribe, España y Portugal
Revista Colombiana de Psiquiatría, Suplemento vol. XXXV / 2006
Ruiz-Flores L. G.
Use of an Electronic Database for Psychiatry
(Microcares™) in Mexico. A Decade of Experience at the
National Medical Center
Luis G. Ruiz-Flores
Psychiatry is without a doubt the branch of medicine most related to
human communication; its core clinical data arise from a skillful inter-
view with at least the dyad patient-psychiatrist, but usually the family
and the medical team are also involved in the recollection of behavioral,
cognitive and emotional data.
Every patient has a different experience of life with his own psychody-
namics and meaning of those events, which the psychiatrist needs to
interpret and translate to medical words judging what seems normal and
what would seem psychopathological.
Psychiatry compared to other specialties in medicine has always had
a special language with an abundance of subjective terms; it is a medical
language but at the same time a psychosocial language closely related to
culture. The enormous task of making these psychiatric terms correlate
with the same reality in different countries has been undertaken suc-
cessfully in the development of the Diagnostic and Statistical Manual
(DSM) but at the cost of over simplifying psychopathology.
- Which are the core data that I need as a doctor to make a psychiatric
- Does this knowledge allow me to understand the bio psychosocial con-
text of this patient and help me place the diagnosis in broad perspec-
* Comment about the article “Adaptation of a Psychosomatic Medicine Computer Record System
for Multi-Language Support: Making Psychiatric Computer Software Regionally Functional in
Spanish-Speaking Countries” (see p. 21-37).
** Talk presented at Microcares’ Annual Meeting May 22nd - 2006, Holiday Inn Hotel, Toronto.
M. D. Department of Psychiatry, National Medical Center, Mexico City. Past president for the
Mexican Psychiatric Association (1998-1999).
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Revista Colombiana de Psiquiatría, Suplemento, vol. XXXV / 2006
Use of an Electronic Database for Psychiatry (Microcares
) in Mexico
- How can I be sure I did not over-
look relevant information for me
or my colleagues?
The process of choosing which
data are necessary to register in
psychiatry is one of the most diffi-
cult tasks for the clinician, you can
go from just filling the blanks of a
standardized form of a Symptom
Check List to a complete and broad
description of experiences like a
professional novelist.
Try to think about these diffi-
culties not only among colleague
psychiatrists but in the arena of a
general hospital with a team of
other medical specialists, with dif-
ferent causes of referral, severe
physical comorbidities and a vari-
ety of medical treatments with the
probability of pharmacological inter-
Almost two decades ago, James
J. Strain MD at the Mount Sinai
hospital in New York begun the de-
velopment of a standardized elec-
tronic psychiatric database that
would be able to gather enough rel-
evant data in the context of a gen-
eral hospital, in order to save time
and allow for a comprehensive clini-
cal record useful for different pur-
poses (hospital notes, clinical re-
search, academic supervision, etc).
I first met him in 1992 at an APA
meeting and asked him specifically
about his experience with trans-
plantation and other C/L psychia-
try issues, kindly he accepted and
during the conversation he told me
that he was developing and using
an electronic database to record his
cases at Mount Sinai Hospital in
New York. From that DOS system
to the one we are using now in Win-
dows there is a big difference spe-
cially now that it is available for
Palm™ .
With his usual generosity Dr.
Strain trusted me a copy of the
Microcares™ electronic database
in 1994, which we use in psychia-
try at the National Medical Center
since then.
It has helped me to develop a
regional database unique to my
country and to answer many of the
questions that clinical psychiatrists
have to deal with in the manage-
ment of a psychiatric service in an
institution and also for the benefit
of my own patients, for example what
amount of antidepressants should
we be allotted during the next six
months? ; Which are the most fre-
quent psychiatric diagnoses at the
hospital?; Why do some patients in
a surgery ward spend more time
hospitalized than others with the
same surgical procedure?, etc.
The database allows for a very
quick and simple ordered gathering
of standardized data for every mem-
ber of the psychiatric department,
same data for everyone regardless
of a biological or psychodynamic bias.
- The database among other many
things takes into account the
time and cause of referral allow-
ing you to record which services
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Revista Colombiana de Psiquiatría, Suplemento vol. XXXV / 2006
Ruiz-Flores L. G.
are more prone to ask a for psy-
chiatric consultation and which
services are closer to making a
reliable psychiatric prediagnosis.
For example, we did an analysis
of the time of referral by clinical
department correlated with the
diagnosis and we were able to
demonstrate that more than
80% of the referrals were not
timely; delirium cases or severe
depressions without treatment
were detected and recorded in
the file at entrance but the re-
ferral was made at least several
days later and after many labo-
ratory and imaging studies; in
many cases emotional problems
were detected in previous
hospitalizations but the patient
was not referred to psychiatry
until the current severe episode.
When we correlated the diagno-
sis of the referral (made by a non
psychiatric specialist) with our
diagnosis we found that only in
half of the cases they were simi-
lar, one example are patients
referred as depression who re-
ally have hipokinetic delirium.
Or patients sent with presump-
tuous schizophrenia which are
really abusing metilphenidate or
having a manic episode.
Surgical services were regularly
less skilled in detecting de-
lirium as they usually think of
it as the common evolution of
surgery and do not regard it as a
different diagnosis.
Medical services usually are
skilled at detecting delirium but
to our surprise less apt to detect
chronic depression as they
think is a conventional part of
the chronic physical illness.
With this in mind, we were able
to develop clinical courses on de-
tection and management of de-
lirium and depression with a
different emphasis for each of
these medical and surgical col-
- Recording the psychiatric his-
tory of the patients and their
families we were able to detect
which groups were vulnerable
and start psycho-education ses-
sions and self help groups for
these special populations. In our
experience, as psychiatric his-
tories carry a stigma it is diffi-
cult to study the families but
with the database it is easier to
form homogeneous groups.
- 67% of the patients seen at the
National Medical Center in
Mexico City, by other specialties
have psychiatric symptoms or a
psychiatric history with enough
relevance to deserve at least one
session with a psychiatrist.
- With the standard method of reg-
istering at our hospital you can
add only one diagnosis, which of
course for medical reasons, usu-
ally is the main physical diag-
nosis. With this database you
can have three medical diag-
noses (DSM Axis III) , and
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Revista Colombiana de Psiquiatría, Suplemento, vol. XXXV / 2006
Use of an Electronic Database for Psychiatry (Microcares
) in Mexico
different spaces to record the
psychiatric diagnoses (Axis I and
II), making it very easy to corre-
late and study comorbidities and
most of all to register exactly the
correct integral diagnosis. One
of the main difficulties we en-
countered before Microcares™
when we were using Excel as
our previous way to enter and
register our data was that de-
pending on the person doing the
job we could have several dif-
ferent answers, for example
speaking about a depressive
episode we could find: (In spa
Depresión, Depresion,
depresión, depresion, episodio
depresivo, Episodio depresivo,
Episodio Depresivo Mayor, episodio
depresivo mayor, DM, EDM
, etc.
and I had to change every item
one by one and standardize the
different ways it was recorded,
usually this standardization took
more time than entering the
data the first time.
However with
the Microcares™ software it is
just a click away to enter exactly
the same diagnosis; and you
even have the option of knowing
if that diagnosis was confirmed
or not later on.
- Adherence to treatment is an-
other important element avail-
able for record with the follow up
of our treatment suggestions. We
have found analyzing our data
that when our treatment sugges-
tion implies diminishing psychi-
atric medication (in number of
tablets or doses), our directions
are usually welcomed and per-
formed with almost a hundred
percent success, but when it is
about influencing the medical
treatment started by others we
only succeed half of the time.
The database allows you to check
which departments are more
confident in your ideas of treat-
ment and to implement a “spe-
cial treatment” with the team
and probably add one or two sci-
entific articles that support your
professional opinion.
- As for medications, you can have
a complete record by clicking
each one at the database and
check its evolution in time, if
they were medically prescribed
or self medicated.; and what kind
of response each one attained.
The average number of medica-
tions in our hospital is 7 differ-
ent drugs, at least a third of the
patients are using or have used
a psychotropic and usually this
was prescribed by a doctor out-
side our hospital or self medi-
cated getting it from a family
- Being a hospital with four hun-
dred residents of different medi-
cal specialties and many pre and
postgraduate students, the Na-
tional Medical Center has be-
come one of the most widely
recognized hospitals in Mexico
for its academic excellence; the
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Revista Colombiana de Psiquiatría, Suplemento vol. XXXV / 2006
Ruiz-Flores L.
option to register data from our
own students and being allowed
to develop specific
tutorial pro-
grams for each one of them is
remarkable. We can easily de-
tect what kind of patients they
have ommited during their
training and
reinforce those
blind areas. An example is that
psychiatric residents in their
first year usually are very simi-
lar to other specialties’ residents
in their psychiatric diagnosis
except for affective disorders, but
after a few months they develop
the skills to recognize for in-
stance a hipokinetic delirium
without thinking that it was only
a depressive episode or worse, a
personality trait. The supervi-
sion of our students is enhanced
by this kind of data.
- A great advance in technology is
to have several psychiatric
scales literally in the palm of
your hand ready to fill in just a
minute, including the Hamilton
for depression, Folstein, Gold-
berg, Glasgow, Arizona Sex scale,
etc. We can see objectively the
progress in the scales from date
to date and even show their own
advances to the patients.
- The data gathered with the soft-
ware has been the best way to
demonstrate the importance and
relevance of our interventions to
the authorities at the hospital
and the rest of the specialties,
not only in terms of quality of life
but also in the spending of eco-
nomical resources (cost-ben-
efit). The richness of data is so
great that usually you don’t get
a hold of all the comparisons that
could be made. It is information
that can be presented in many
different papers in other special-
ties’ journals and our own. A
clear example of this opportunity
is the work done by Graeme
Smith MD, psychiatrist and
friend in Australia who has pub-
lished not less than 16 papers
using this database.
- For research purposes it is the
quickest and easiest way to
record relevant psychiatric clini-
cal data ready to be compared
with other databases from gen-
eral hospital psychiatric units in
Mexico or other countries.
Six years ago I had the opportu-
nity to participate with Dr.
Strain in a presentation at the
Mexican Psychiatric Association
annual meeting in Cancún,
showing data from
a small sam-
ple of consultations (500 pa-
tients) from our hospital
with Dr. Strain’s huge
database (several thousands) at
the Mount Sinai hospital in New
York. The comparison demon-
strated the differences and simi-
larities of treatment between the
two clinical groups.
- Not all is milk and honey. The
main difficulty encountered
along the way was not the bar-
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Revista Colombiana de Psiquiatría, Suplemento, vol. XXXV / 2006
Use of an Electronic Database for Psychiatry (Microcares
) in Mexico
rier of technology prices in
Mexico or the barrier of lan-
guage, but that too often the data
were filled incomplete, I used to
think that the ommisions were
because of time limitations but
I have seen that most of all it is
the attitude, since people are not
used to register other data that
may not seem relevant at the
time of the consultation but that
are necessary for later purposes.
- We are still gathering more and
more data with the Microcares
software, and the new genera-
tion of psychiatric residents can
behold the impact of this data in
their own graduation thesis.
para publicación
: 24 de mayo de 2006
Aceptado para publicación
: 30 de mayo de 2006
Luis G. Ruiz-Flores
Departamento de Psiquiatría
Centro Médico Nacional
México D. F., México
Correo electrónico:
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