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When is technology ready for mainstream use for mental health care?
It is a daunting task for mental health providers to stay abreast with the current technology options available for mental health treatment. The past decade has seen the rise of multiple technology platforms with applications in mental health treatment (e.g., videoconferencing, mobile phones, web, patient-portals) along with specific interventions tailored to these platforms.
Traditional mechanisms for providers and mental health organizations, such as research papers and educational trainings, are unable to keep pace with both the technology available for providers and the technology being used by patients. How does a busy individual provider or mental health organization assess whether a technology is at a point to be considered a mainstream intervention and should be considered for routine use in clinical practice?
I proffer here the “middle caribou theory” for adapting “new” treatments and interventions. In a migrating caribou herd, animals leading the pack risk breaking through thin ice or getting pushed off unexpected cliffs by the masses behind them before the herd can institute a course correction. The caribou at the back of the herd are vulnerable to predation from wolves. The astute provider, like the caribou in the middle of the herd, has allowed others to test the path ahead and is less likely to be put at risk from antiquated methodologies found at the back of the herd.
There are now “base” technologies that every mental health provider and organization should be proficient in using and incorporating into clinical services where appropriate. These include email, videoconferencing, web-based technologies (e.g., patient education, patient portals) electronic medical records, and mobile phone-based applications. These are technologies that are relatively mature, and have reasonable track records in administrative and clinical psychiatry, in addition to growing or developed scientific literature supporting their use. “Emergent” technologies are those being deployed in clinical practice that have not reached widespread use and have underdeveloped literature and track records for their use. Examples of these include texting, virtual reality, and location technologies.1
Base vs. emergent technologies offer a framework for providers to determine which technologies they should be using in their practices. Often, it’s difficult to pinpoint when a technology has reached a “tipping point” into becoming a base/standard technology in the field and should be carefully considered by the middle caribou. Arguably, this occurs when a combination of a growing body of scientific evidence supporting a technology is coupled with wide adoption, although these two factors are not necessarily correlated. There are many examples in psychiatry of treatments coming into widespread practice with limited scientific support as well as scientifically robust treatments not being used in practice. Funding and reimbursement structures also play a role in facilitating and encouraging deployment and adoption of technology in mental health – and are not always driven by scientific best practices.
Finally, the temperament of individual providers and organizations determines when and how adoption might occur. Risk tolerance, novelty seeking, and capacity affect whether someone is an early or late adopter of an innovation.
Ultimately, clinical necessity drives the use of technologies in practice. Often, technology that has proved useful in other medical fields or in general use is translated into mental health, rather than being de novo developed for specific mental health treatments. This type of cross-pollination is not negative. Instead, it carries the risk of an initial “halo effect” where the promise of a technology used in other settings creates an unrealistic set of expectations about its potential in mental health treatments. This can lead to premature use and wider adoption that outpaces supporting scientific evidence.
So what should psychiatric providers and organizations consider in approaching these issues?
• Be proficient in base technologies, and stay up to date in their evolving uses and refinement.
• Stay informed about developing technologies, particularly those gaining broader use.
• Before considering adapting a new technology into clinical practice, make sure one is up to date on the scientific evidence supporting the technology. Providers should consider specialized training and orientation before piloting a new technology within a clinical setting.
• Take advantage of, and follow guidance of, reviews and best practices for assessing technology fit.
Dr. Shore chairs the American Psychiatric Association’s Committee on Telepsychiatry and is director of telemedicine at the Helen & Arthur E. Johnson Depression Center at the University of Colorado at Denver, Aurora. He also serves as associate professor of psychiatry at the university.
References
1 Telepsychiatry and Health Technologies: A Guide for Mental Health Professionals Arlington, Va.: American Psychiatric Association Publishing, 2017.
2 Telemed J E Health. 2015;21(12):1038-41.
3 Mil Med. 2014 Aug;179(8):865-78.
It is a daunting task for mental health providers to stay abreast with the current technology options available for mental health treatment. The past decade has seen the rise of multiple technology platforms with applications in mental health treatment (e.g., videoconferencing, mobile phones, web, patient-portals) along with specific interventions tailored to these platforms.
Traditional mechanisms for providers and mental health organizations, such as research papers and educational trainings, are unable to keep pace with both the technology available for providers and the technology being used by patients. How does a busy individual provider or mental health organization assess whether a technology is at a point to be considered a mainstream intervention and should be considered for routine use in clinical practice?
I proffer here the “middle caribou theory” for adapting “new” treatments and interventions. In a migrating caribou herd, animals leading the pack risk breaking through thin ice or getting pushed off unexpected cliffs by the masses behind them before the herd can institute a course correction. The caribou at the back of the herd are vulnerable to predation from wolves. The astute provider, like the caribou in the middle of the herd, has allowed others to test the path ahead and is less likely to be put at risk from antiquated methodologies found at the back of the herd.
There are now “base” technologies that every mental health provider and organization should be proficient in using and incorporating into clinical services where appropriate. These include email, videoconferencing, web-based technologies (e.g., patient education, patient portals) electronic medical records, and mobile phone-based applications. These are technologies that are relatively mature, and have reasonable track records in administrative and clinical psychiatry, in addition to growing or developed scientific literature supporting their use. “Emergent” technologies are those being deployed in clinical practice that have not reached widespread use and have underdeveloped literature and track records for their use. Examples of these include texting, virtual reality, and location technologies.1
Base vs. emergent technologies offer a framework for providers to determine which technologies they should be using in their practices. Often, it’s difficult to pinpoint when a technology has reached a “tipping point” into becoming a base/standard technology in the field and should be carefully considered by the middle caribou. Arguably, this occurs when a combination of a growing body of scientific evidence supporting a technology is coupled with wide adoption, although these two factors are not necessarily correlated. There are many examples in psychiatry of treatments coming into widespread practice with limited scientific support as well as scientifically robust treatments not being used in practice. Funding and reimbursement structures also play a role in facilitating and encouraging deployment and adoption of technology in mental health – and are not always driven by scientific best practices.
Finally, the temperament of individual providers and organizations determines when and how adoption might occur. Risk tolerance, novelty seeking, and capacity affect whether someone is an early or late adopter of an innovation.
Ultimately, clinical necessity drives the use of technologies in practice. Often, technology that has proved useful in other medical fields or in general use is translated into mental health, rather than being de novo developed for specific mental health treatments. This type of cross-pollination is not negative. Instead, it carries the risk of an initial “halo effect” where the promise of a technology used in other settings creates an unrealistic set of expectations about its potential in mental health treatments. This can lead to premature use and wider adoption that outpaces supporting scientific evidence.
So what should psychiatric providers and organizations consider in approaching these issues?
• Be proficient in base technologies, and stay up to date in their evolving uses and refinement.
• Stay informed about developing technologies, particularly those gaining broader use.
• Before considering adapting a new technology into clinical practice, make sure one is up to date on the scientific evidence supporting the technology. Providers should consider specialized training and orientation before piloting a new technology within a clinical setting.
• Take advantage of, and follow guidance of, reviews and best practices for assessing technology fit.
Dr. Shore chairs the American Psychiatric Association’s Committee on Telepsychiatry and is director of telemedicine at the Helen & Arthur E. Johnson Depression Center at the University of Colorado at Denver, Aurora. He also serves as associate professor of psychiatry at the university.
References
1 Telepsychiatry and Health Technologies: A Guide for Mental Health Professionals Arlington, Va.: American Psychiatric Association Publishing, 2017.
2 Telemed J E Health. 2015;21(12):1038-41.
3 Mil Med. 2014 Aug;179(8):865-78.
It is a daunting task for mental health providers to stay abreast with the current technology options available for mental health treatment. The past decade has seen the rise of multiple technology platforms with applications in mental health treatment (e.g., videoconferencing, mobile phones, web, patient-portals) along with specific interventions tailored to these platforms.
Traditional mechanisms for providers and mental health organizations, such as research papers and educational trainings, are unable to keep pace with both the technology available for providers and the technology being used by patients. How does a busy individual provider or mental health organization assess whether a technology is at a point to be considered a mainstream intervention and should be considered for routine use in clinical practice?
I proffer here the “middle caribou theory” for adapting “new” treatments and interventions. In a migrating caribou herd, animals leading the pack risk breaking through thin ice or getting pushed off unexpected cliffs by the masses behind them before the herd can institute a course correction. The caribou at the back of the herd are vulnerable to predation from wolves. The astute provider, like the caribou in the middle of the herd, has allowed others to test the path ahead and is less likely to be put at risk from antiquated methodologies found at the back of the herd.
There are now “base” technologies that every mental health provider and organization should be proficient in using and incorporating into clinical services where appropriate. These include email, videoconferencing, web-based technologies (e.g., patient education, patient portals) electronic medical records, and mobile phone-based applications. These are technologies that are relatively mature, and have reasonable track records in administrative and clinical psychiatry, in addition to growing or developed scientific literature supporting their use. “Emergent” technologies are those being deployed in clinical practice that have not reached widespread use and have underdeveloped literature and track records for their use. Examples of these include texting, virtual reality, and location technologies.1
Base vs. emergent technologies offer a framework for providers to determine which technologies they should be using in their practices. Often, it’s difficult to pinpoint when a technology has reached a “tipping point” into becoming a base/standard technology in the field and should be carefully considered by the middle caribou. Arguably, this occurs when a combination of a growing body of scientific evidence supporting a technology is coupled with wide adoption, although these two factors are not necessarily correlated. There are many examples in psychiatry of treatments coming into widespread practice with limited scientific support as well as scientifically robust treatments not being used in practice. Funding and reimbursement structures also play a role in facilitating and encouraging deployment and adoption of technology in mental health – and are not always driven by scientific best practices.
Finally, the temperament of individual providers and organizations determines when and how adoption might occur. Risk tolerance, novelty seeking, and capacity affect whether someone is an early or late adopter of an innovation.
Ultimately, clinical necessity drives the use of technologies in practice. Often, technology that has proved useful in other medical fields or in general use is translated into mental health, rather than being de novo developed for specific mental health treatments. This type of cross-pollination is not negative. Instead, it carries the risk of an initial “halo effect” where the promise of a technology used in other settings creates an unrealistic set of expectations about its potential in mental health treatments. This can lead to premature use and wider adoption that outpaces supporting scientific evidence.
So what should psychiatric providers and organizations consider in approaching these issues?
• Be proficient in base technologies, and stay up to date in their evolving uses and refinement.
• Stay informed about developing technologies, particularly those gaining broader use.
• Before considering adapting a new technology into clinical practice, make sure one is up to date on the scientific evidence supporting the technology. Providers should consider specialized training and orientation before piloting a new technology within a clinical setting.
• Take advantage of, and follow guidance of, reviews and best practices for assessing technology fit.
Dr. Shore chairs the American Psychiatric Association’s Committee on Telepsychiatry and is director of telemedicine at the Helen & Arthur E. Johnson Depression Center at the University of Colorado at Denver, Aurora. He also serves as associate professor of psychiatry at the university.
References
1 Telepsychiatry and Health Technologies: A Guide for Mental Health Professionals Arlington, Va.: American Psychiatric Association Publishing, 2017.
2 Telemed J E Health. 2015;21(12):1038-41.
3 Mil Med. 2014 Aug;179(8):865-78.
Digital transference: New dangers in a new world
We are in a new age of psychiatric practice caught in the wider shift from an industrial to a technology-based society. Although this transformation has been occurring over the past half-century, the last decade has seen a rapid acceleration driven by mobile phones, social networking, and the Internet.
Thomas Friedman, in his book “Thank you for Being Late: An Optimist’s Guide to Thriving in the Age of Accelerations” (New York: Farrar, Straus & Girous, 2016), cites 2007 as the year our world changed with the launching of the iPhone, the globalization of Facebook and Twitter, the release of the Kindle and Android, the founding of Airbnb, Google’s purchase of YouTube, and IBM’s creation of its AI system, Watson. Psychiatry has been gradually incorporating technology into everyday practice using mobile devices, email, videoconferencing, Internet, and electronic medical records, as well as being impacted by more rapidly evolving technologies, such as texting and social networking platforms.
Transference remains a core tenant in the psychiatric conceptualization of the psychiatrist-patient relationship. There are numerous formal definitions of this phenomenon. This article will use a broad reductionist definition of transference as the “unconscious projection of a past relationship/experience onto a current relationship” and combine the terms transference (from patient to psychiatrist) and countertransference (from psychiatrist to patient; often defined as a psychiatrist’s reaction to a patient’s transference).
How do a psychiatrist and patient dyad’s previous experiences with technology and technology-based relationships affect a current clinical relationship? How does the type of technology being used influence shared meanings and assumptions? Does technology introduce new implicit biases that go unrecognized? Does distant communication increase the risk of missing contextual clues more apparent for in-person interactions? These critical questions have largely gone unaddressed, but what is known raises concerns. The question is not whether to use these technologies, which have demonstrated utility to transform care. Rather, concerns around our lack of understanding of the technologies’ strengths, weaknesses, and influences on the doctor-patient relationship need to be explored. Below we will briefly examine each of these questions.
A relatively new paradigm has been inserting itself from the field of education into medicine that describes a patient’s previous technology experiences. “Digital immigrants” is a term for those who did not grow up with today’s technology and began using our current technologies as adults. They contrast with “digital natives,” who have grown up incorporating technology into their daily lives. Broad assumptions are that digital natives tend to be more comfortable, flexible, and adaptable with technologies, compared with digital immigrants, who are more hesitant and slower to adopt and integrate technology. However, the experience of a specific patient with technology is multifactorial and more nuanced than the digital native vs. digital immigrant classification. There are those who argue that technology use from an early age is altering on a biological level the way the human brain processes both information and emotion. Depending on their experiences and backgrounds (immigrant vs. native), a psychiatrist and patient using videoconferencing to enable remote access could have initial as well as ongoing positive or negative transferences to treatment.
The specific technology being used also sets parameters for communication that influence interpretation. Text and email communication are very different from live interactive video conferencing and involve use of language that may not be shared between the psychiatrist and patient, such as text abbreviations and emojis. Lack of visual and auditory information necessitates more interpretation by the receiver to fill in tone, meaning, and intent drawn from their past conscious and unconscious experiences and assumptions. The opportunity for misinterpretation is further compounded by implicit bias built into the technology. Although biases embedded in medical technologies have yet to be examined, there are some alarming examples from society in general.
A recent report by the Georgetown University’s Center on Privacy & Technology drew attention to inherent racial bias in facial recognition technology used by law enforcement agencies. This bias was a product of both the underlying software and programming, as well as the real world implementation of these systems. As the field of medicine increasingly turns to artificial intelligence for help with pattern recognition, data management, and population health, what implicit biases are being built into these systems? Could a web-assisted, evidence-based therapy that uses an algorithmic approach have built-in biases for certain populations of patients, affecting the therapeutic interaction?
A final issue worth considering is the power of technology to distort shared context. When a psychiatrist meets with a patient in person, they are sharing the same environmental context at the same point of time during treatment. When communicating over distance, they are occupying different environments and, with asynchronous communication (for example, email), different points in time. These disparate contexts may lend themselves to additional assumptions that get projected onto the clinical relationship. For example, a telepsychiatrist working with Northern Plains Indian Communities via videoconferencing has a new patient in a new clinic setting visually similar to other clinics they have visited in the past. If not mindful of context, the telepsychiatrist may risk making unwarranted assumptions about the patient’s environmental context based on the physician’s previous work. In a different example, a psychiatrist sees a patient for an in-person visit and then reads an email sent 12 hours prior to the visit by the patient expressing upset at psychiatrist’s structuring of treatment. This issue was not addressed in the session that just ended. What is the impact of this email to both the psychiatrist and patient, and their current feelings about the therapeutic relationship? Is this now current or past context for the patient and psychiatrist?
For many, questions about bias, context, and previous experiences with technology can be seen as “grist for the mill” for psychiatrists to understand the transferences and other processes within doctor-patient relationships. This knowledge can then be leveraged to appropriately attend to the therapeutic relationship. The danger in the age of hybrid relationships is when there are embedded issues that psychiatry as a field and individual psychiatrists are unaware of and not attending to in treatment. As the acknowledged experts in medicine in the doctor-patient relationship say, psychiatrists need to take leadership roles in better understanding the impact of technologies on clinical processes – both for those processes on the surface, as well as those that lurk beneath the digital waves.
Dr. Shore chairs the American Psychiatric Association’s Committee on Telepsychiatry and is director of telemedicine at the Helen & Arthur E. Johnson Depression Center at the University of Colorado at Denver, Aurora. He also serves as associate professor of psychiatry at the university.
We are in a new age of psychiatric practice caught in the wider shift from an industrial to a technology-based society. Although this transformation has been occurring over the past half-century, the last decade has seen a rapid acceleration driven by mobile phones, social networking, and the Internet.
Thomas Friedman, in his book “Thank you for Being Late: An Optimist’s Guide to Thriving in the Age of Accelerations” (New York: Farrar, Straus & Girous, 2016), cites 2007 as the year our world changed with the launching of the iPhone, the globalization of Facebook and Twitter, the release of the Kindle and Android, the founding of Airbnb, Google’s purchase of YouTube, and IBM’s creation of its AI system, Watson. Psychiatry has been gradually incorporating technology into everyday practice using mobile devices, email, videoconferencing, Internet, and electronic medical records, as well as being impacted by more rapidly evolving technologies, such as texting and social networking platforms.
Transference remains a core tenant in the psychiatric conceptualization of the psychiatrist-patient relationship. There are numerous formal definitions of this phenomenon. This article will use a broad reductionist definition of transference as the “unconscious projection of a past relationship/experience onto a current relationship” and combine the terms transference (from patient to psychiatrist) and countertransference (from psychiatrist to patient; often defined as a psychiatrist’s reaction to a patient’s transference).
How do a psychiatrist and patient dyad’s previous experiences with technology and technology-based relationships affect a current clinical relationship? How does the type of technology being used influence shared meanings and assumptions? Does technology introduce new implicit biases that go unrecognized? Does distant communication increase the risk of missing contextual clues more apparent for in-person interactions? These critical questions have largely gone unaddressed, but what is known raises concerns. The question is not whether to use these technologies, which have demonstrated utility to transform care. Rather, concerns around our lack of understanding of the technologies’ strengths, weaknesses, and influences on the doctor-patient relationship need to be explored. Below we will briefly examine each of these questions.
A relatively new paradigm has been inserting itself from the field of education into medicine that describes a patient’s previous technology experiences. “Digital immigrants” is a term for those who did not grow up with today’s technology and began using our current technologies as adults. They contrast with “digital natives,” who have grown up incorporating technology into their daily lives. Broad assumptions are that digital natives tend to be more comfortable, flexible, and adaptable with technologies, compared with digital immigrants, who are more hesitant and slower to adopt and integrate technology. However, the experience of a specific patient with technology is multifactorial and more nuanced than the digital native vs. digital immigrant classification. There are those who argue that technology use from an early age is altering on a biological level the way the human brain processes both information and emotion. Depending on their experiences and backgrounds (immigrant vs. native), a psychiatrist and patient using videoconferencing to enable remote access could have initial as well as ongoing positive or negative transferences to treatment.
The specific technology being used also sets parameters for communication that influence interpretation. Text and email communication are very different from live interactive video conferencing and involve use of language that may not be shared between the psychiatrist and patient, such as text abbreviations and emojis. Lack of visual and auditory information necessitates more interpretation by the receiver to fill in tone, meaning, and intent drawn from their past conscious and unconscious experiences and assumptions. The opportunity for misinterpretation is further compounded by implicit bias built into the technology. Although biases embedded in medical technologies have yet to be examined, there are some alarming examples from society in general.
A recent report by the Georgetown University’s Center on Privacy & Technology drew attention to inherent racial bias in facial recognition technology used by law enforcement agencies. This bias was a product of both the underlying software and programming, as well as the real world implementation of these systems. As the field of medicine increasingly turns to artificial intelligence for help with pattern recognition, data management, and population health, what implicit biases are being built into these systems? Could a web-assisted, evidence-based therapy that uses an algorithmic approach have built-in biases for certain populations of patients, affecting the therapeutic interaction?
A final issue worth considering is the power of technology to distort shared context. When a psychiatrist meets with a patient in person, they are sharing the same environmental context at the same point of time during treatment. When communicating over distance, they are occupying different environments and, with asynchronous communication (for example, email), different points in time. These disparate contexts may lend themselves to additional assumptions that get projected onto the clinical relationship. For example, a telepsychiatrist working with Northern Plains Indian Communities via videoconferencing has a new patient in a new clinic setting visually similar to other clinics they have visited in the past. If not mindful of context, the telepsychiatrist may risk making unwarranted assumptions about the patient’s environmental context based on the physician’s previous work. In a different example, a psychiatrist sees a patient for an in-person visit and then reads an email sent 12 hours prior to the visit by the patient expressing upset at psychiatrist’s structuring of treatment. This issue was not addressed in the session that just ended. What is the impact of this email to both the psychiatrist and patient, and their current feelings about the therapeutic relationship? Is this now current or past context for the patient and psychiatrist?
For many, questions about bias, context, and previous experiences with technology can be seen as “grist for the mill” for psychiatrists to understand the transferences and other processes within doctor-patient relationships. This knowledge can then be leveraged to appropriately attend to the therapeutic relationship. The danger in the age of hybrid relationships is when there are embedded issues that psychiatry as a field and individual psychiatrists are unaware of and not attending to in treatment. As the acknowledged experts in medicine in the doctor-patient relationship say, psychiatrists need to take leadership roles in better understanding the impact of technologies on clinical processes – both for those processes on the surface, as well as those that lurk beneath the digital waves.
Dr. Shore chairs the American Psychiatric Association’s Committee on Telepsychiatry and is director of telemedicine at the Helen & Arthur E. Johnson Depression Center at the University of Colorado at Denver, Aurora. He also serves as associate professor of psychiatry at the university.
We are in a new age of psychiatric practice caught in the wider shift from an industrial to a technology-based society. Although this transformation has been occurring over the past half-century, the last decade has seen a rapid acceleration driven by mobile phones, social networking, and the Internet.
Thomas Friedman, in his book “Thank you for Being Late: An Optimist’s Guide to Thriving in the Age of Accelerations” (New York: Farrar, Straus & Girous, 2016), cites 2007 as the year our world changed with the launching of the iPhone, the globalization of Facebook and Twitter, the release of the Kindle and Android, the founding of Airbnb, Google’s purchase of YouTube, and IBM’s creation of its AI system, Watson. Psychiatry has been gradually incorporating technology into everyday practice using mobile devices, email, videoconferencing, Internet, and electronic medical records, as well as being impacted by more rapidly evolving technologies, such as texting and social networking platforms.
Transference remains a core tenant in the psychiatric conceptualization of the psychiatrist-patient relationship. There are numerous formal definitions of this phenomenon. This article will use a broad reductionist definition of transference as the “unconscious projection of a past relationship/experience onto a current relationship” and combine the terms transference (from patient to psychiatrist) and countertransference (from psychiatrist to patient; often defined as a psychiatrist’s reaction to a patient’s transference).
How do a psychiatrist and patient dyad’s previous experiences with technology and technology-based relationships affect a current clinical relationship? How does the type of technology being used influence shared meanings and assumptions? Does technology introduce new implicit biases that go unrecognized? Does distant communication increase the risk of missing contextual clues more apparent for in-person interactions? These critical questions have largely gone unaddressed, but what is known raises concerns. The question is not whether to use these technologies, which have demonstrated utility to transform care. Rather, concerns around our lack of understanding of the technologies’ strengths, weaknesses, and influences on the doctor-patient relationship need to be explored. Below we will briefly examine each of these questions.
A relatively new paradigm has been inserting itself from the field of education into medicine that describes a patient’s previous technology experiences. “Digital immigrants” is a term for those who did not grow up with today’s technology and began using our current technologies as adults. They contrast with “digital natives,” who have grown up incorporating technology into their daily lives. Broad assumptions are that digital natives tend to be more comfortable, flexible, and adaptable with technologies, compared with digital immigrants, who are more hesitant and slower to adopt and integrate technology. However, the experience of a specific patient with technology is multifactorial and more nuanced than the digital native vs. digital immigrant classification. There are those who argue that technology use from an early age is altering on a biological level the way the human brain processes both information and emotion. Depending on their experiences and backgrounds (immigrant vs. native), a psychiatrist and patient using videoconferencing to enable remote access could have initial as well as ongoing positive or negative transferences to treatment.
The specific technology being used also sets parameters for communication that influence interpretation. Text and email communication are very different from live interactive video conferencing and involve use of language that may not be shared between the psychiatrist and patient, such as text abbreviations and emojis. Lack of visual and auditory information necessitates more interpretation by the receiver to fill in tone, meaning, and intent drawn from their past conscious and unconscious experiences and assumptions. The opportunity for misinterpretation is further compounded by implicit bias built into the technology. Although biases embedded in medical technologies have yet to be examined, there are some alarming examples from society in general.
A recent report by the Georgetown University’s Center on Privacy & Technology drew attention to inherent racial bias in facial recognition technology used by law enforcement agencies. This bias was a product of both the underlying software and programming, as well as the real world implementation of these systems. As the field of medicine increasingly turns to artificial intelligence for help with pattern recognition, data management, and population health, what implicit biases are being built into these systems? Could a web-assisted, evidence-based therapy that uses an algorithmic approach have built-in biases for certain populations of patients, affecting the therapeutic interaction?
A final issue worth considering is the power of technology to distort shared context. When a psychiatrist meets with a patient in person, they are sharing the same environmental context at the same point of time during treatment. When communicating over distance, they are occupying different environments and, with asynchronous communication (for example, email), different points in time. These disparate contexts may lend themselves to additional assumptions that get projected onto the clinical relationship. For example, a telepsychiatrist working with Northern Plains Indian Communities via videoconferencing has a new patient in a new clinic setting visually similar to other clinics they have visited in the past. If not mindful of context, the telepsychiatrist may risk making unwarranted assumptions about the patient’s environmental context based on the physician’s previous work. In a different example, a psychiatrist sees a patient for an in-person visit and then reads an email sent 12 hours prior to the visit by the patient expressing upset at psychiatrist’s structuring of treatment. This issue was not addressed in the session that just ended. What is the impact of this email to both the psychiatrist and patient, and their current feelings about the therapeutic relationship? Is this now current or past context for the patient and psychiatrist?
For many, questions about bias, context, and previous experiences with technology can be seen as “grist for the mill” for psychiatrists to understand the transferences and other processes within doctor-patient relationships. This knowledge can then be leveraged to appropriately attend to the therapeutic relationship. The danger in the age of hybrid relationships is when there are embedded issues that psychiatry as a field and individual psychiatrists are unaware of and not attending to in treatment. As the acknowledged experts in medicine in the doctor-patient relationship say, psychiatrists need to take leadership roles in better understanding the impact of technologies on clinical processes – both for those processes on the surface, as well as those that lurk beneath the digital waves.
Dr. Shore chairs the American Psychiatric Association’s Committee on Telepsychiatry and is director of telemedicine at the Helen & Arthur E. Johnson Depression Center at the University of Colorado at Denver, Aurora. He also serves as associate professor of psychiatry at the university.
‘Doc in a box’ vs.’tele-teaming’: Contending models of telepsychiatric care
As articulated by Steve Daviss, MD, DFAPA, in the inaugural column of Techiatry, the adoption and diffusion of telepsychiatry (live two-way interactive videoconferencing) have not been as rapid and universal as expected from those of us immersed in the field.
Despite having yet to achieve its full promise, telepsychiatry has reached maturity, and is being widely deployed and used across multiple systems, settings, and applications, albeit at times in an uneven, unsystematic manner. Emerging over the past decade of development are two distinct models/approaches to telepsychiatry, which I refer to as “doc in a box” and “tele-teaming.” Those models coexist, compete, and conflict within and across organizations. The dynamic between those two models highlights a larger emergent dialogue within psychiatry around psychiatrists’ core clinical roles and functions in our evolving health care systems.
The doc in a box model, as captured in early telepsychiatry services in the 1990s and early 2000s, focused on the virtual insertion of a solo psychiatrist into a distant setting. The services involved core psychiatric activities, such as diagnosis and assessment, with a heavy emphasis on pharmacologic management.
Not surprisingly, those services paralleled what was occurring for the rest of psychiatry at the time and were driven by the closer alignment of psychiatry with a biologic framework – and most importantly, reimbursement models that favored pharmacologic interventions and management. The subsequent rise of viable commercial telepsychiatry companies has continued offering this model driven by demands of the marketplace. While there is a legitimate place and need for such services, the phrase “doc in a box” narrows the scope of psychiatric practice, and reinforces current systems of health care structure and funding.
I proffer the phrase “tele-teaming” to denote telepsychiatric care that virtually embeds a psychiatrist as a member of a care team at a distant location. The use of telepsychiatry in integrated care is the clearest example of this. In integrated care, a psychiatrist works as part of a larger behavioral and medical team that may include case managers, social workers, psychologists, nurses, and family physicians to render care to patients in primary care clinics. The psychiatrist performs consultative, direct care, and supervisory roles in the context of the integrated care team, focusing on more holistic and population-based approaches to treatment.
Telepsychiatry, as well as other technologies (for example, electronic medical records, email, and patient registries), enables and enhances integrated care. Telepsychiatry allows smaller primary care practices, which on their own could not support a full-time psychiatrist, to create a full virtual team across multiple sites.
Tele-teaming as a concept is not limited to integrated care. Other notable examples include the use of telepsychiatry in substance rehabilitation facilities, long-term nursing homes, and psychiatric emergency services as a component of ERs. Tele-teaming and doc in a box models are not about the settings or populations to which they provide care, but the structure and philosophy of the psychiatric service.
As an illustration, imagine a rural community mental health center whose long-term psychiatric care provider retires. The center could set up a contract with a psychiatrist to provide medication management services for its patients through telepsychiatry. The psychiatrist, armed with a pen or eprescribing credentials, could provide several days a week of medication management. Treatment planning, therapy, and care coordination could be segmented off to other providers from the center (psychologists, social workers, and case managers). The psychiatrist’s time could be maximized by having the psychiatrist manage prescriptions, with communication between the patients’ various providers through a shared electronic medical record, as in the doc in a box model.
Alternatively, the center could set up a service where the psychiatrist became a virtual team member working to provide complete assessments, treatment planning, supervision, and psychiatric consultation, as well as pharmacologic management. Although in this scenario, the psychiatrist still could devote time to managing prescriptions, she/he also could spend time in team meetings, supervision, and seeing patients, often with her colleagues. In addition, the psychiatrist could work to coordinate care beyond the EMR, for example, through tele-teaming. Either of these scenarios can and do occur with in-person care as well, and the choice of which model to use would not be decided by the technology but by the underlying health care system in which it is being used.
Telepsychiatry begins to become transformative when it’s leveraged to shift, change, or innovate the model of care delivery. Historically, telepsychiatry has been thought of as a solution to patient access issues and as a way to address workforce shortages. The real promise of telepsychiatry in the form of tele-teaming is how it can begin to fundamentally change how care is delivered. The triple aim calls for decreased costs, improved health care for individuals, and a focus on population health.
We know that most Americans with major mental health issues will be seen in primary care, and that providing behavioral health care in primary care settings leads to lower overall health care costs, and improved behavioral and general health outcomes. Telepsychiatry will be essential in the further dissemination and expansion of integrated care, not only in rural and underserved areas, but across large health care systems. Tele-teaming will be essential in other arenas as well, as psychiatry faces the future challenges of an aging and decreasing (per capita) workforce. Team approaches help maximize psychiatrists’ role in the health care system, and help magnify the number of patients their skills and training can support.
Team approaches also help to broaden the scope of psychiatric practice and reclaim psychiatry’s place within the house of medicine. Telepsychiatry, if structured correctly, helps increase flexibility for psychiatrists. It expands the settings available to practice and provides more opportunities to engage in team-based care. Both the doc in a box and tele-teaming models have arisen from forces in the health care marketplace. The differing application of those two models across and within health care systems illustrates overall tensions within psychiatry about the current and future roles of psychiatrists.
Telepsychiatry is a powerful tool that can be leveraged to shape models of psychiatric care delivery or reinforce our existing structures. Which models are embraced will affect how psychiatry continues to evolve and address the challenges before the specialty.
Dr. Shore chairs the American Psychiatric Association’s Committee on Telepsychiatry, and is director of telemedicine at the Helen & Arthur E. Johnson Depression Center and associate professor of psychiatry at the University of Colorado at Denver, Aurora.
As articulated by Steve Daviss, MD, DFAPA, in the inaugural column of Techiatry, the adoption and diffusion of telepsychiatry (live two-way interactive videoconferencing) have not been as rapid and universal as expected from those of us immersed in the field.
Despite having yet to achieve its full promise, telepsychiatry has reached maturity, and is being widely deployed and used across multiple systems, settings, and applications, albeit at times in an uneven, unsystematic manner. Emerging over the past decade of development are two distinct models/approaches to telepsychiatry, which I refer to as “doc in a box” and “tele-teaming.” Those models coexist, compete, and conflict within and across organizations. The dynamic between those two models highlights a larger emergent dialogue within psychiatry around psychiatrists’ core clinical roles and functions in our evolving health care systems.
The doc in a box model, as captured in early telepsychiatry services in the 1990s and early 2000s, focused on the virtual insertion of a solo psychiatrist into a distant setting. The services involved core psychiatric activities, such as diagnosis and assessment, with a heavy emphasis on pharmacologic management.
Not surprisingly, those services paralleled what was occurring for the rest of psychiatry at the time and were driven by the closer alignment of psychiatry with a biologic framework – and most importantly, reimbursement models that favored pharmacologic interventions and management. The subsequent rise of viable commercial telepsychiatry companies has continued offering this model driven by demands of the marketplace. While there is a legitimate place and need for such services, the phrase “doc in a box” narrows the scope of psychiatric practice, and reinforces current systems of health care structure and funding.
I proffer the phrase “tele-teaming” to denote telepsychiatric care that virtually embeds a psychiatrist as a member of a care team at a distant location. The use of telepsychiatry in integrated care is the clearest example of this. In integrated care, a psychiatrist works as part of a larger behavioral and medical team that may include case managers, social workers, psychologists, nurses, and family physicians to render care to patients in primary care clinics. The psychiatrist performs consultative, direct care, and supervisory roles in the context of the integrated care team, focusing on more holistic and population-based approaches to treatment.
Telepsychiatry, as well as other technologies (for example, electronic medical records, email, and patient registries), enables and enhances integrated care. Telepsychiatry allows smaller primary care practices, which on their own could not support a full-time psychiatrist, to create a full virtual team across multiple sites.
Tele-teaming as a concept is not limited to integrated care. Other notable examples include the use of telepsychiatry in substance rehabilitation facilities, long-term nursing homes, and psychiatric emergency services as a component of ERs. Tele-teaming and doc in a box models are not about the settings or populations to which they provide care, but the structure and philosophy of the psychiatric service.
As an illustration, imagine a rural community mental health center whose long-term psychiatric care provider retires. The center could set up a contract with a psychiatrist to provide medication management services for its patients through telepsychiatry. The psychiatrist, armed with a pen or eprescribing credentials, could provide several days a week of medication management. Treatment planning, therapy, and care coordination could be segmented off to other providers from the center (psychologists, social workers, and case managers). The psychiatrist’s time could be maximized by having the psychiatrist manage prescriptions, with communication between the patients’ various providers through a shared electronic medical record, as in the doc in a box model.
Alternatively, the center could set up a service where the psychiatrist became a virtual team member working to provide complete assessments, treatment planning, supervision, and psychiatric consultation, as well as pharmacologic management. Although in this scenario, the psychiatrist still could devote time to managing prescriptions, she/he also could spend time in team meetings, supervision, and seeing patients, often with her colleagues. In addition, the psychiatrist could work to coordinate care beyond the EMR, for example, through tele-teaming. Either of these scenarios can and do occur with in-person care as well, and the choice of which model to use would not be decided by the technology but by the underlying health care system in which it is being used.
Telepsychiatry begins to become transformative when it’s leveraged to shift, change, or innovate the model of care delivery. Historically, telepsychiatry has been thought of as a solution to patient access issues and as a way to address workforce shortages. The real promise of telepsychiatry in the form of tele-teaming is how it can begin to fundamentally change how care is delivered. The triple aim calls for decreased costs, improved health care for individuals, and a focus on population health.
We know that most Americans with major mental health issues will be seen in primary care, and that providing behavioral health care in primary care settings leads to lower overall health care costs, and improved behavioral and general health outcomes. Telepsychiatry will be essential in the further dissemination and expansion of integrated care, not only in rural and underserved areas, but across large health care systems. Tele-teaming will be essential in other arenas as well, as psychiatry faces the future challenges of an aging and decreasing (per capita) workforce. Team approaches help maximize psychiatrists’ role in the health care system, and help magnify the number of patients their skills and training can support.
Team approaches also help to broaden the scope of psychiatric practice and reclaim psychiatry’s place within the house of medicine. Telepsychiatry, if structured correctly, helps increase flexibility for psychiatrists. It expands the settings available to practice and provides more opportunities to engage in team-based care. Both the doc in a box and tele-teaming models have arisen from forces in the health care marketplace. The differing application of those two models across and within health care systems illustrates overall tensions within psychiatry about the current and future roles of psychiatrists.
Telepsychiatry is a powerful tool that can be leveraged to shape models of psychiatric care delivery or reinforce our existing structures. Which models are embraced will affect how psychiatry continues to evolve and address the challenges before the specialty.
Dr. Shore chairs the American Psychiatric Association’s Committee on Telepsychiatry, and is director of telemedicine at the Helen & Arthur E. Johnson Depression Center and associate professor of psychiatry at the University of Colorado at Denver, Aurora.
As articulated by Steve Daviss, MD, DFAPA, in the inaugural column of Techiatry, the adoption and diffusion of telepsychiatry (live two-way interactive videoconferencing) have not been as rapid and universal as expected from those of us immersed in the field.
Despite having yet to achieve its full promise, telepsychiatry has reached maturity, and is being widely deployed and used across multiple systems, settings, and applications, albeit at times in an uneven, unsystematic manner. Emerging over the past decade of development are two distinct models/approaches to telepsychiatry, which I refer to as “doc in a box” and “tele-teaming.” Those models coexist, compete, and conflict within and across organizations. The dynamic between those two models highlights a larger emergent dialogue within psychiatry around psychiatrists’ core clinical roles and functions in our evolving health care systems.
The doc in a box model, as captured in early telepsychiatry services in the 1990s and early 2000s, focused on the virtual insertion of a solo psychiatrist into a distant setting. The services involved core psychiatric activities, such as diagnosis and assessment, with a heavy emphasis on pharmacologic management.
Not surprisingly, those services paralleled what was occurring for the rest of psychiatry at the time and were driven by the closer alignment of psychiatry with a biologic framework – and most importantly, reimbursement models that favored pharmacologic interventions and management. The subsequent rise of viable commercial telepsychiatry companies has continued offering this model driven by demands of the marketplace. While there is a legitimate place and need for such services, the phrase “doc in a box” narrows the scope of psychiatric practice, and reinforces current systems of health care structure and funding.
I proffer the phrase “tele-teaming” to denote telepsychiatric care that virtually embeds a psychiatrist as a member of a care team at a distant location. The use of telepsychiatry in integrated care is the clearest example of this. In integrated care, a psychiatrist works as part of a larger behavioral and medical team that may include case managers, social workers, psychologists, nurses, and family physicians to render care to patients in primary care clinics. The psychiatrist performs consultative, direct care, and supervisory roles in the context of the integrated care team, focusing on more holistic and population-based approaches to treatment.
Telepsychiatry, as well as other technologies (for example, electronic medical records, email, and patient registries), enables and enhances integrated care. Telepsychiatry allows smaller primary care practices, which on their own could not support a full-time psychiatrist, to create a full virtual team across multiple sites.
Tele-teaming as a concept is not limited to integrated care. Other notable examples include the use of telepsychiatry in substance rehabilitation facilities, long-term nursing homes, and psychiatric emergency services as a component of ERs. Tele-teaming and doc in a box models are not about the settings or populations to which they provide care, but the structure and philosophy of the psychiatric service.
As an illustration, imagine a rural community mental health center whose long-term psychiatric care provider retires. The center could set up a contract with a psychiatrist to provide medication management services for its patients through telepsychiatry. The psychiatrist, armed with a pen or eprescribing credentials, could provide several days a week of medication management. Treatment planning, therapy, and care coordination could be segmented off to other providers from the center (psychologists, social workers, and case managers). The psychiatrist’s time could be maximized by having the psychiatrist manage prescriptions, with communication between the patients’ various providers through a shared electronic medical record, as in the doc in a box model.
Alternatively, the center could set up a service where the psychiatrist became a virtual team member working to provide complete assessments, treatment planning, supervision, and psychiatric consultation, as well as pharmacologic management. Although in this scenario, the psychiatrist still could devote time to managing prescriptions, she/he also could spend time in team meetings, supervision, and seeing patients, often with her colleagues. In addition, the psychiatrist could work to coordinate care beyond the EMR, for example, through tele-teaming. Either of these scenarios can and do occur with in-person care as well, and the choice of which model to use would not be decided by the technology but by the underlying health care system in which it is being used.
Telepsychiatry begins to become transformative when it’s leveraged to shift, change, or innovate the model of care delivery. Historically, telepsychiatry has been thought of as a solution to patient access issues and as a way to address workforce shortages. The real promise of telepsychiatry in the form of tele-teaming is how it can begin to fundamentally change how care is delivered. The triple aim calls for decreased costs, improved health care for individuals, and a focus on population health.
We know that most Americans with major mental health issues will be seen in primary care, and that providing behavioral health care in primary care settings leads to lower overall health care costs, and improved behavioral and general health outcomes. Telepsychiatry will be essential in the further dissemination and expansion of integrated care, not only in rural and underserved areas, but across large health care systems. Tele-teaming will be essential in other arenas as well, as psychiatry faces the future challenges of an aging and decreasing (per capita) workforce. Team approaches help maximize psychiatrists’ role in the health care system, and help magnify the number of patients their skills and training can support.
Team approaches also help to broaden the scope of psychiatric practice and reclaim psychiatry’s place within the house of medicine. Telepsychiatry, if structured correctly, helps increase flexibility for psychiatrists. It expands the settings available to practice and provides more opportunities to engage in team-based care. Both the doc in a box and tele-teaming models have arisen from forces in the health care marketplace. The differing application of those two models across and within health care systems illustrates overall tensions within psychiatry about the current and future roles of psychiatrists.
Telepsychiatry is a powerful tool that can be leveraged to shape models of psychiatric care delivery or reinforce our existing structures. Which models are embraced will affect how psychiatry continues to evolve and address the challenges before the specialty.
Dr. Shore chairs the American Psychiatric Association’s Committee on Telepsychiatry, and is director of telemedicine at the Helen & Arthur E. Johnson Depression Center and associate professor of psychiatry at the University of Colorado at Denver, Aurora.