Techiatry

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.

There are plenty of published guidelines, best practices, and recommendations to the field for providers on how to understand and assess specific technologies as to readiness and fit for individual or organizational practice settings. For example, several reviews focus on apps in mental health that include recommendations on criteria for app assessment.^2,3 These types of approaches can provide a structured process to address questions about whether to begin using a technology but not necessarily when or how.

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.

There are plenty of published guidelines, best practices, and recommendations to the field for providers on how to understand and assess specific technologies as to readiness and fit for individual or organizational practice settings. For example, several reviews focus on apps in mental health that include recommendations on criteria for app assessment.^2,3 These types of approaches can provide a structured process to address questions about whether to begin using a technology but not necessarily when or how.

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.

There are plenty of published guidelines, best practices, and recommendations to the field for providers on how to understand and assess specific technologies as to readiness and fit for individual or organizational practice settings. For example, several reviews focus on apps in mental health that include recommendations on criteria for app assessment.^2,3 These types of approaches can provide a structured process to address questions about whether to begin using a technology but not necessarily when or how.

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.

 

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.

The 21^st-century psychiatrist will need to become adept at managing the doctor-patient relationship across a hybrid of different technologies. The processes and interaction that encompass the doctor-patient relationship are no longer limited to in-person contact and occur across a variety of formats, including in-person, via videoconferencing, email, text, web-based patient portals, and mobile phones. Despite the shifting nature of psychiatrist-patient communication, little is known about the impact of the “hybrid relationship” on clinical processes, such as rapport, understanding, and transference.

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.

The 21^st-century psychiatrist will need to become adept at managing the doctor-patient relationship across a hybrid of different technologies. The processes and interaction that encompass the doctor-patient relationship are no longer limited to in-person contact and occur across a variety of formats, including in-person, via videoconferencing, email, text, web-based patient portals, and mobile phones. Despite the shifting nature of psychiatrist-patient communication, little is known about the impact of the “hybrid relationship” on clinical processes, such as rapport, understanding, and transference.

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.

The 21^st-century psychiatrist will need to become adept at managing the doctor-patient relationship across a hybrid of different technologies. The processes and interaction that encompass the doctor-patient relationship are no longer limited to in-person contact and occur across a variety of formats, including in-person, via videoconferencing, email, text, web-based patient portals, and mobile phones. Despite the shifting nature of psychiatrist-patient communication, little is known about the impact of the “hybrid relationship” on clinical processes, such as rapport, understanding, and transference.

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.

 

“Often, innovation is a product of desperation. I have seen too many of my patients die from opioid overdoses, and I’ve decided to create something that can stop this.”

This is the opening description of an innovative idea that Joseph Insler, MD, an early–career psychiatrist in Boston, pitched to the judges last October.

As one of the judges, this is how I described the item: “It’s like a Fitbit for people addicted to opioids, who are at risk of overdose. But, instead of tracking your footsteps and your sleep movements, it tracks your blood oxygen level, heart rate, and lack of movement. Based on an algorithm tuned to identify signs of an overdose, the Opioid Overdose Recovery Bracelet would give you a shot of medicine in your wrist. If you have accidentally overdosed, it will give you a premeasured dose of naloxone from its reservoir, likely saving your life.”

Courtesy Dr. Steven R. Daviss

This is one of the many innovative pitches that was made at the American Psychiatric Association’s second Psychiatry Innovation Lab last October in Washington. The lab was created by Nina Vasan, MD, a Stanford (Calif.) University psychiatrist completing her residency while also enrolled in the university’s MBA program. The first lab was held at the APA annual meeting in May 2016 in Atlanta.

The goal of the Psychiatry Innovation Lab is to catalyze the formation of innovative ventures to transform mental health. “We nurture early stage ideas and ventures by investing in them with mentorship, education, funding, and collaboration opportunities with our community of mental health innovators,” Dr. Vasan said. At its core, the lab is an interactive exercise in experiential learning, where participants learn how to develop and pitch an entrepreneurial idea and then work together with experts in real time to improve their idea so that they leave with a solid plan for improving mental health. A panel of judges and leaders in innovation collaborate by providing feedback and mentoring. The competition event uses a “Shark Tank” style of winnowing out competitors but is a friendlier format than that of the TV show.

“There’s been a real call to action for using entrepreneurship to change the future, and the Psychiatry Innovation Lab is our answer to that call,” Dr. Vasan said. “We’ve had finalists ranging from high school students to emeritus professors. We’ve seen ideas for [anything from] advancing human rights all the way to using technology to improve access to care.”

Access to mental health and addiction care is one of the driving forces behind a recent wave of investment in behavioral health. There is a lot of interest now in how newer technologies can be leveraged in to improve access, screening, prevention, analytics, and treatments. Younger people coming into the field now have a much shorter path between idea and action. “Think of the lab as a place where people turn their idealism into impact. They learn how to create change that reflects our values: effective, measurable, collaborative, affordable, and sustainable.”

Early career psychiatrists have been particularly drawn to the use of technology to improve their work,” said John Torous, MD, codirector of the digital psychiatry program at Beth Israel Deaconess Medical Center and Harvard Medical School, both in Boston. Paul O’Leary, MD, founding president of SHKO Medicine in Birmingham, Ala., thinks that the APA’s focus on technology is key for attracting young psychiatrists. “The innovation lab offers a glimpse into the future of psychiatry. More than that, it offers residents and early career psychiatrists a real opportunity to make a meaningful contribution to our profession. This is really the TED talks for psychiatry.”

New lab will set records

On May 21, at the APA annual meeting in San Diego, the third Innovation Lab event will take place with record sponsorship and funding. More than $30,000 in prizes will be awarded to winning teams in the following categories: Grand Prize, Audience Choice, Outstanding Progress, Most Promising Innovation, and Most Disruptive Innovation. New this year, the Accelerator Prize will be awarded to the alumni team that has made the most progress since its participation in a previous Innovation Lab. A special prize from Google, worth $20,000, will be given to the innovation that best uses the potential of Cloud services, including Web applications, software, and machine learning.

Courtesy Dr. Steven R. Daviss

The concept of an Innovation Lab has been expanded into what the APA is calling the Innovation Zone, a catalyst for the advancement of new mental health technologies. Indeed, the APA has been embracing many forms of new technology, including mobile health apps, a mental health registry, electronic health records, telepsychiatry, and involvement in Health Level 7, which advocates for health information technology standards that account for the needs of psychiatrists and our patients.

Also, on May 21, the live Innovation Lab event will begin with the seven finalists giving initial pitches about their innovative ideas for improving mental health care delivery and how psychiatrists are diagnosing, treating, or managing patients. In addition, 10 semifinalists will be selected to deliver rapid pitches. Audience members will then vote from their devices, and the top semifinalist will proceed as a finalist. The event will end with an evening networking session aimed at building community and collaborations among mental health innovators, including clinicians, entrepreneurs, engineers, investors, and patients.

To learn more or watch videos about these innovators, go to www.psychiatryinnovation.com, or search for “APA innovation lab.”

 

Dr. Daviss is the chief medical informatics officer at M3 Information and chairs the American Psychiatric Association’s Committee on Mental Health Information Technology.

Psychiatry Innovation Lab alumni

Entrepreneurs from the October 2016 competition created products that addressed addiction, autism, Alzheimer’s, posttraumatic stress disorder, and other mental disorders.

Finalists

• Overdose Recovery Bracelet – “A novel solution to the opioid epidemic” – Joseph Insler
• Spectrum – “An app to encourage facial processing and emotion recognition in autism spectrum disorder” – Swathi Krishna
• Spring – “Enabling personalized behavioral healthcare using machine learning and big data” – April Koh
• Alzhelp – “Using augmented reality and intelligent personal assistant software to keep Alzheimer’s patients safe” – Akanksha Jain, Michelle Koh, and Priscilla Siow
• MiHelper – “Identifying patterns of distress and determining optimal periods for real time mental health interventions” – Kammarauche Isuzu and Mackenzie Drazan
• WEmbrace – “A mobile application for foreign-background psychiatric patients to effectively provide critical care” – Ellen Oh

Semifinalists

• Broadleaf Mental Health –“Reaching school-aged children in the rural eastern Himalayas” – Michael Matergia
• TechLink – “Connecting students and tech” – Akanksha Jain, Michelle Koh, and Priscilla Siow
• Beacon – “Smarter therapy. Together” – Shrenik Jain and Ravi Shah
• Muse – “Assisted meditation in mental health” – Graeme Moffat
• MiResource – “Helping adolescents find the right therapeutic fit” – Gabriela Asturias and Mackenzie Drazen
• BraVe Reality – “Virtual treatment for PTSD patients” – Monica Kullar
• SKNR – “A user-centric psychotherapy tool for the digital age” – Hyun-Hee Kim
• We2Link – “Connect better” – Michael Malone PRISM – “Helping patients gain insight through digital art mobile app” – Kenechi Ejebe and Whitney McFadden

SOURCE: Dr. Daviss

 

“Often, innovation is a product of desperation. I have seen too many of my patients die from opioid overdoses, and I’ve decided to create something that can stop this.”

This is the opening description of an innovative idea that Joseph Insler, MD, an early–career psychiatrist in Boston, pitched to the judges last October.

As one of the judges, this is how I described the item: “It’s like a Fitbit for people addicted to opioids, who are at risk of overdose. But, instead of tracking your footsteps and your sleep movements, it tracks your blood oxygen level, heart rate, and lack of movement. Based on an algorithm tuned to identify signs of an overdose, the Opioid Overdose Recovery Bracelet would give you a shot of medicine in your wrist. If you have accidentally overdosed, it will give you a premeasured dose of naloxone from its reservoir, likely saving your life.”

Courtesy Dr. Steven R. Daviss

This is one of the many innovative pitches that was made at the American Psychiatric Association’s second Psychiatry Innovation Lab last October in Washington. The lab was created by Nina Vasan, MD, a Stanford (Calif.) University psychiatrist completing her residency while also enrolled in the university’s MBA program. The first lab was held at the APA annual meeting in May 2016 in Atlanta.

The goal of the Psychiatry Innovation Lab is to catalyze the formation of innovative ventures to transform mental health. “We nurture early stage ideas and ventures by investing in them with mentorship, education, funding, and collaboration opportunities with our community of mental health innovators,” Dr. Vasan said. At its core, the lab is an interactive exercise in experiential learning, where participants learn how to develop and pitch an entrepreneurial idea and then work together with experts in real time to improve their idea so that they leave with a solid plan for improving mental health. A panel of judges and leaders in innovation collaborate by providing feedback and mentoring. The competition event uses a “Shark Tank” style of winnowing out competitors but is a friendlier format than that of the TV show.

“There’s been a real call to action for using entrepreneurship to change the future, and the Psychiatry Innovation Lab is our answer to that call,” Dr. Vasan said. “We’ve had finalists ranging from high school students to emeritus professors. We’ve seen ideas for [anything from] advancing human rights all the way to using technology to improve access to care.”

Access to mental health and addiction care is one of the driving forces behind a recent wave of investment in behavioral health. There is a lot of interest now in how newer technologies can be leveraged in to improve access, screening, prevention, analytics, and treatments. Younger people coming into the field now have a much shorter path between idea and action. “Think of the lab as a place where people turn their idealism into impact. They learn how to create change that reflects our values: effective, measurable, collaborative, affordable, and sustainable.”

Early career psychiatrists have been particularly drawn to the use of technology to improve their work,” said John Torous, MD, codirector of the digital psychiatry program at Beth Israel Deaconess Medical Center and Harvard Medical School, both in Boston. Paul O’Leary, MD, founding president of SHKO Medicine in Birmingham, Ala., thinks that the APA’s focus on technology is key for attracting young psychiatrists. “The innovation lab offers a glimpse into the future of psychiatry. More than that, it offers residents and early career psychiatrists a real opportunity to make a meaningful contribution to our profession. This is really the TED talks for psychiatry.”

New lab will set records

On May 21, at the APA annual meeting in San Diego, the third Innovation Lab event will take place with record sponsorship and funding. More than $30,000 in prizes will be awarded to winning teams in the following categories: Grand Prize, Audience Choice, Outstanding Progress, Most Promising Innovation, and Most Disruptive Innovation. New this year, the Accelerator Prize will be awarded to the alumni team that has made the most progress since its participation in a previous Innovation Lab. A special prize from Google, worth $20,000, will be given to the innovation that best uses the potential of Cloud services, including Web applications, software, and machine learning.

Courtesy Dr. Steven R. Daviss

The concept of an Innovation Lab has been expanded into what the APA is calling the Innovation Zone, a catalyst for the advancement of new mental health technologies. Indeed, the APA has been embracing many forms of new technology, including mobile health apps, a mental health registry, electronic health records, telepsychiatry, and involvement in Health Level 7, which advocates for health information technology standards that account for the needs of psychiatrists and our patients.

Also, on May 21, the live Innovation Lab event will begin with the seven finalists giving initial pitches about their innovative ideas for improving mental health care delivery and how psychiatrists are diagnosing, treating, or managing patients. In addition, 10 semifinalists will be selected to deliver rapid pitches. Audience members will then vote from their devices, and the top semifinalist will proceed as a finalist. The event will end with an evening networking session aimed at building community and collaborations among mental health innovators, including clinicians, entrepreneurs, engineers, investors, and patients.

To learn more or watch videos about these innovators, go to www.psychiatryinnovation.com, or search for “APA innovation lab.”

 

Dr. Daviss is the chief medical informatics officer at M3 Information and chairs the American Psychiatric Association’s Committee on Mental Health Information Technology.

Psychiatry Innovation Lab alumni

Entrepreneurs from the October 2016 competition created products that addressed addiction, autism, Alzheimer’s, posttraumatic stress disorder, and other mental disorders.

Finalists

• Overdose Recovery Bracelet – “A novel solution to the opioid epidemic” – Joseph Insler
• Spectrum – “An app to encourage facial processing and emotion recognition in autism spectrum disorder” – Swathi Krishna
• Spring – “Enabling personalized behavioral healthcare using machine learning and big data” – April Koh
• Alzhelp – “Using augmented reality and intelligent personal assistant software to keep Alzheimer’s patients safe” – Akanksha Jain, Michelle Koh, and Priscilla Siow
• MiHelper – “Identifying patterns of distress and determining optimal periods for real time mental health interventions” – Kammarauche Isuzu and Mackenzie Drazan
• WEmbrace – “A mobile application for foreign-background psychiatric patients to effectively provide critical care” – Ellen Oh

Semifinalists

• Broadleaf Mental Health –“Reaching school-aged children in the rural eastern Himalayas” – Michael Matergia
• TechLink – “Connecting students and tech” – Akanksha Jain, Michelle Koh, and Priscilla Siow
• Beacon – “Smarter therapy. Together” – Shrenik Jain and Ravi Shah
• Muse – “Assisted meditation in mental health” – Graeme Moffat
• MiResource – “Helping adolescents find the right therapeutic fit” – Gabriela Asturias and Mackenzie Drazen
• BraVe Reality – “Virtual treatment for PTSD patients” – Monica Kullar
• SKNR – “A user-centric psychotherapy tool for the digital age” – Hyun-Hee Kim
• We2Link – “Connect better” – Michael Malone PRISM – “Helping patients gain insight through digital art mobile app” – Kenechi Ejebe and Whitney McFadden

SOURCE: Dr. Daviss

 

“Often, innovation is a product of desperation. I have seen too many of my patients die from opioid overdoses, and I’ve decided to create something that can stop this.”

This is the opening description of an innovative idea that Joseph Insler, MD, an early–career psychiatrist in Boston, pitched to the judges last October.

As one of the judges, this is how I described the item: “It’s like a Fitbit for people addicted to opioids, who are at risk of overdose. But, instead of tracking your footsteps and your sleep movements, it tracks your blood oxygen level, heart rate, and lack of movement. Based on an algorithm tuned to identify signs of an overdose, the Opioid Overdose Recovery Bracelet would give you a shot of medicine in your wrist. If you have accidentally overdosed, it will give you a premeasured dose of naloxone from its reservoir, likely saving your life.”

Courtesy Dr. Steven R. Daviss

This is one of the many innovative pitches that was made at the American Psychiatric Association’s second Psychiatry Innovation Lab last October in Washington. The lab was created by Nina Vasan, MD, a Stanford (Calif.) University psychiatrist completing her residency while also enrolled in the university’s MBA program. The first lab was held at the APA annual meeting in May 2016 in Atlanta.

The goal of the Psychiatry Innovation Lab is to catalyze the formation of innovative ventures to transform mental health. “We nurture early stage ideas and ventures by investing in them with mentorship, education, funding, and collaboration opportunities with our community of mental health innovators,” Dr. Vasan said. At its core, the lab is an interactive exercise in experiential learning, where participants learn how to develop and pitch an entrepreneurial idea and then work together with experts in real time to improve their idea so that they leave with a solid plan for improving mental health. A panel of judges and leaders in innovation collaborate by providing feedback and mentoring. The competition event uses a “Shark Tank” style of winnowing out competitors but is a friendlier format than that of the TV show.

“There’s been a real call to action for using entrepreneurship to change the future, and the Psychiatry Innovation Lab is our answer to that call,” Dr. Vasan said. “We’ve had finalists ranging from high school students to emeritus professors. We’ve seen ideas for [anything from] advancing human rights all the way to using technology to improve access to care.”

Access to mental health and addiction care is one of the driving forces behind a recent wave of investment in behavioral health. There is a lot of interest now in how newer technologies can be leveraged in to improve access, screening, prevention, analytics, and treatments. Younger people coming into the field now have a much shorter path between idea and action. “Think of the lab as a place where people turn their idealism into impact. They learn how to create change that reflects our values: effective, measurable, collaborative, affordable, and sustainable.”

Early career psychiatrists have been particularly drawn to the use of technology to improve their work,” said John Torous, MD, codirector of the digital psychiatry program at Beth Israel Deaconess Medical Center and Harvard Medical School, both in Boston. Paul O’Leary, MD, founding president of SHKO Medicine in Birmingham, Ala., thinks that the APA’s focus on technology is key for attracting young psychiatrists. “The innovation lab offers a glimpse into the future of psychiatry. More than that, it offers residents and early career psychiatrists a real opportunity to make a meaningful contribution to our profession. This is really the TED talks for psychiatry.”

New lab will set records

On May 21, at the APA annual meeting in San Diego, the third Innovation Lab event will take place with record sponsorship and funding. More than $30,000 in prizes will be awarded to winning teams in the following categories: Grand Prize, Audience Choice, Outstanding Progress, Most Promising Innovation, and Most Disruptive Innovation. New this year, the Accelerator Prize will be awarded to the alumni team that has made the most progress since its participation in a previous Innovation Lab. A special prize from Google, worth $20,000, will be given to the innovation that best uses the potential of Cloud services, including Web applications, software, and machine learning.

Courtesy Dr. Steven R. Daviss

The concept of an Innovation Lab has been expanded into what the APA is calling the Innovation Zone, a catalyst for the advancement of new mental health technologies. Indeed, the APA has been embracing many forms of new technology, including mobile health apps, a mental health registry, electronic health records, telepsychiatry, and involvement in Health Level 7, which advocates for health information technology standards that account for the needs of psychiatrists and our patients.

Also, on May 21, the live Innovation Lab event will begin with the seven finalists giving initial pitches about their innovative ideas for improving mental health care delivery and how psychiatrists are diagnosing, treating, or managing patients. In addition, 10 semifinalists will be selected to deliver rapid pitches. Audience members will then vote from their devices, and the top semifinalist will proceed as a finalist. The event will end with an evening networking session aimed at building community and collaborations among mental health innovators, including clinicians, entrepreneurs, engineers, investors, and patients.

To learn more or watch videos about these innovators, go to www.psychiatryinnovation.com, or search for “APA innovation lab.”

 

Dr. Daviss is the chief medical informatics officer at M3 Information and chairs the American Psychiatric Association’s Committee on Mental Health Information Technology.

Psychiatry Innovation Lab alumni

Entrepreneurs from the October 2016 competition created products that addressed addiction, autism, Alzheimer’s, posttraumatic stress disorder, and other mental disorders.

Finalists

• Overdose Recovery Bracelet – “A novel solution to the opioid epidemic” – Joseph Insler
• Spectrum – “An app to encourage facial processing and emotion recognition in autism spectrum disorder” – Swathi Krishna
• Spring – “Enabling personalized behavioral healthcare using machine learning and big data” – April Koh
• Alzhelp – “Using augmented reality and intelligent personal assistant software to keep Alzheimer’s patients safe” – Akanksha Jain, Michelle Koh, and Priscilla Siow
• MiHelper – “Identifying patterns of distress and determining optimal periods for real time mental health interventions” – Kammarauche Isuzu and Mackenzie Drazan
• WEmbrace – “A mobile application for foreign-background psychiatric patients to effectively provide critical care” – Ellen Oh

Semifinalists

• Broadleaf Mental Health –“Reaching school-aged children in the rural eastern Himalayas” – Michael Matergia
• TechLink – “Connecting students and tech” – Akanksha Jain, Michelle Koh, and Priscilla Siow
• Beacon – “Smarter therapy. Together” – Shrenik Jain and Ravi Shah
• Muse – “Assisted meditation in mental health” – Graeme Moffat
• MiResource – “Helping adolescents find the right therapeutic fit” – Gabriela Asturias and Mackenzie Drazen
• BraVe Reality – “Virtual treatment for PTSD patients” – Monica Kullar
• SKNR – “A user-centric psychotherapy tool for the digital age” – Hyun-Hee Kim
• We2Link – “Connect better” – Michael Malone PRISM – “Helping patients gain insight through digital art mobile app” – Kenechi Ejebe and Whitney McFadden

SOURCE: Dr. Daviss

 

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 phrase “doc in a box” has been bantered about in telemedicine for quite some time. Although it does not have a universally accepted definition, generally, the phrase implies physician-delivered care via videoconferencing, often through large room-based or cart-based TV systems. I first consistently encountered the term in a longstanding telepsychiatry service where the patients affectionately used it to refer to me and my fellow provider. The phrase itself is ambiguous. For me, it conjures up the image of a solo psychiatrist providing medication management via video.

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 phrase “doc in a box” has been bantered about in telemedicine for quite some time. Although it does not have a universally accepted definition, generally, the phrase implies physician-delivered care via videoconferencing, often through large room-based or cart-based TV systems. I first consistently encountered the term in a longstanding telepsychiatry service where the patients affectionately used it to refer to me and my fellow provider. The phrase itself is ambiguous. For me, it conjures up the image of a solo psychiatrist providing medication management via video.

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 phrase “doc in a box” has been bantered about in telemedicine for quite some time. Although it does not have a universally accepted definition, generally, the phrase implies physician-delivered care via videoconferencing, often through large room-based or cart-based TV systems. I first consistently encountered the term in a longstanding telepsychiatry service where the patients affectionately used it to refer to me and my fellow provider. The phrase itself is ambiguous. For me, it conjures up the image of a solo psychiatrist providing medication management via video.

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.

 

Editors’ Note: The intent of this new column is to discuss topics at the intersection of technology and psychiatry – “Techiatry.” We’ve enlisted two leaders in this field to write for the column. Steven R. Daviss, MD, DFAPA (@HITshrink), is the chief medical informatics officer at M3 Information and chairs the American Psychiatric Association’s Committee on Mental Health Information Technology. James (Jay) H. Shore, MD, MPH, chairs the APA Committee on Telepsychiatry, is director of telemedicine at the Helen & Arthur E. Johnson Depression Center, and an associate professor of psychiatry at the University of Colorado at Denver, Aurora. Email them at [email protected].
 

Medicine is late to the game when it comes to technology, specifically information technology. And psychiatry, even more so. Jay will talk in future columns about early use of telepsychiatry in the 1960s and since. But here in 2016, a surprisingly low percentage of us are using it to deliver care, despite the fact that half of the counties in the United States lack psychiatrists – and telemedicine has been shown to improve access to care.

Nonetheless, telemedicine and other uses of technology across all specialties is growing quickly, as usability, mobile technology, economics, and policy-making all converge. The integration of mental health care (including addiction treatment) with primary care is one of the driving forces in expanding access to the expertise that physicians trained in psychiatry possess. The collaborative care model of integrated care has the most evidence, making regular access to psychiatric consultants a weekly event.

Most people with mental health problems are treated in primary care settings, yet many of those settings are unlikely to use this type of integrated care. What I find most interesting about the collaborative care model is that information is the main currency, not direct patient care. The primary care practitioners and care managers distill known information about their patients, and communicate this information by both story and data to the collaborating psychiatrists. In turn, the psychiatrist assesses the knowledge gaps that could affect their decision making (“Do you know if there is a family history of bipolar disorder?” “Why did she stop the lithium?”) to improve their recommendations to the team.

This exchange of information and knowledge between primary care and psychiatry is being formally incentivized by the Centers for Medicare & Medicaid Services (CMS) with proposed new codes to pay for this exchange, while the American Psychiatric Association has received a large grant from CMS to train 10% of its members in this care model.

Information technology is fundamental to this care model, because the efficient exchange of clinical information is important to optimize the capabilities and comprehensiveness of the clinical decision support provided by the psychiatrist to the primary care team.

As the team members learn what questions are asked and how the consultant arrives at her recommendations, they will become better at making these decisions on their own. They will learn how psychiatrists think and make decisions, weighing other medical, personal, social, family, and logistical aspects to guide the decision making process with the patient.

While this model of care is certainly helpful in expanding access to psychiatric expertise, there are other ways to achieve this access to expert knowledge. One of them is through electronic clinical decision support (CDS) tools. These are tools that apply clinical rules, algorithms, and other knowledge discovery processes to the information within the electronic health record (EHR) about a patient, with the goal of assessing and filling gaps in available patient information so that a set of possible recommendations can be delivered to the clinician.

Knowledge-based CDS tools apply clinical knowledge that comes from practice guidelines, textbooks, and the medical literature to what is known about the patient. The simplest CDS tool might be a rule that says, “IF patient is on lithium for bipolar disorder AND patient has current mood symptoms AND has not had a recent lithium level, THEN check a lithium level.” Applying and coding this rule into an EHR is fairly straightforward. A much more complex CDS tool could help the clinician think through the question, “What should I do next for this 32yo woman with hypertension and moderate depression who is symptomatic?”

Non–knowledge-based CDS tools use machine learning techniques, like neural networks, genetic algorithms, and natural language processing, to “learn” new clinical rules by going through a training process that inputs a large amount of clinical data and uses experts to “train” the system. Such a system was recently developed by IBM Watson and Memorial Sloan-Kettering Cancer Center to aid in developing recommendations for treating oncology patients.

The APA recently formed the CDS Product Workgroup (which I chair) to explore the feasibility of developing an electronic clinical decision support (CDS) tool that leverages the information and knowledge within the APA’s series of Practice Guidelines, DSM library, and other reference materials. This group will consider the necessary important clinical information sources – such as EHRs, personal health records, health information exchanges, claims and utilization data, patient generated data, mobile health apps, and clinical registries ­– from which to analyze patient-­specific data and produce a set of ranked, evidence­-based, annotated clinical suggestions.

The goal is to develop a CDS tool that is designed in a manner that ultimately benefits patients being treated by primary care practitioners, emergency practitioners, psychiatrists, and other medical specialists who treat patients with mental health and substance use disorders. Tools like this are being developed now in many specialties. Given the vast amount of psychiatric expertise within the APA, as well as the trove of content that exists within the publishing arm of the APA, the opportunity to make this more broadly available to medical practitioners is one that demands consideration.

Such an undertaking would require substantial time and commitment of resources, thus the task of the workgroup is to understand the pros and cons of developing this tool, and to explore its feasibility, including various business models to ensure that this CDS tool becomes a maintainable and sustainable product.

Bringing our expertise to the primary care settings, where most of our patients are treated, should greatly benefit the care of our patients, whether this is through collaborative care, clinical decision support, or telepsychiatry. In the same way that many people with diabetes do not require an endocrinologist, many with mental health conditions do not require a psychiatrist. Yet, primary care practitioners would certainly benefit from more help from us.

I will update readers of this column on our workgroup’s progress at the end of the year.

 

Editors’ Note: The intent of this new column is to discuss topics at the intersection of technology and psychiatry – “Techiatry.” We’ve enlisted two leaders in this field to write for the column. Steven R. Daviss, MD, DFAPA (@HITshrink), is the chief medical informatics officer at M3 Information and chairs the American Psychiatric Association’s Committee on Mental Health Information Technology. James (Jay) H. Shore, MD, MPH, chairs the APA Committee on Telepsychiatry, is director of telemedicine at the Helen & Arthur E. Johnson Depression Center, and an associate professor of psychiatry at the University of Colorado at Denver, Aurora. Email them at [email protected].
 

Medicine is late to the game when it comes to technology, specifically information technology. And psychiatry, even more so. Jay will talk in future columns about early use of telepsychiatry in the 1960s and since. But here in 2016, a surprisingly low percentage of us are using it to deliver care, despite the fact that half of the counties in the United States lack psychiatrists – and telemedicine has been shown to improve access to care.

Nonetheless, telemedicine and other uses of technology across all specialties is growing quickly, as usability, mobile technology, economics, and policy-making all converge. The integration of mental health care (including addiction treatment) with primary care is one of the driving forces in expanding access to the expertise that physicians trained in psychiatry possess. The collaborative care model of integrated care has the most evidence, making regular access to psychiatric consultants a weekly event.

Most people with mental health problems are treated in primary care settings, yet many of those settings are unlikely to use this type of integrated care. What I find most interesting about the collaborative care model is that information is the main currency, not direct patient care. The primary care practitioners and care managers distill known information about their patients, and communicate this information by both story and data to the collaborating psychiatrists. In turn, the psychiatrist assesses the knowledge gaps that could affect their decision making (“Do you know if there is a family history of bipolar disorder?” “Why did she stop the lithium?”) to improve their recommendations to the team.

This exchange of information and knowledge between primary care and psychiatry is being formally incentivized by the Centers for Medicare & Medicaid Services (CMS) with proposed new codes to pay for this exchange, while the American Psychiatric Association has received a large grant from CMS to train 10% of its members in this care model.

Information technology is fundamental to this care model, because the efficient exchange of clinical information is important to optimize the capabilities and comprehensiveness of the clinical decision support provided by the psychiatrist to the primary care team.

As the team members learn what questions are asked and how the consultant arrives at her recommendations, they will become better at making these decisions on their own. They will learn how psychiatrists think and make decisions, weighing other medical, personal, social, family, and logistical aspects to guide the decision making process with the patient.

While this model of care is certainly helpful in expanding access to psychiatric expertise, there are other ways to achieve this access to expert knowledge. One of them is through electronic clinical decision support (CDS) tools. These are tools that apply clinical rules, algorithms, and other knowledge discovery processes to the information within the electronic health record (EHR) about a patient, with the goal of assessing and filling gaps in available patient information so that a set of possible recommendations can be delivered to the clinician.

Knowledge-based CDS tools apply clinical knowledge that comes from practice guidelines, textbooks, and the medical literature to what is known about the patient. The simplest CDS tool might be a rule that says, “IF patient is on lithium for bipolar disorder AND patient has current mood symptoms AND has not had a recent lithium level, THEN check a lithium level.” Applying and coding this rule into an EHR is fairly straightforward. A much more complex CDS tool could help the clinician think through the question, “What should I do next for this 32yo woman with hypertension and moderate depression who is symptomatic?”

Non–knowledge-based CDS tools use machine learning techniques, like neural networks, genetic algorithms, and natural language processing, to “learn” new clinical rules by going through a training process that inputs a large amount of clinical data and uses experts to “train” the system. Such a system was recently developed by IBM Watson and Memorial Sloan-Kettering Cancer Center to aid in developing recommendations for treating oncology patients.

The APA recently formed the CDS Product Workgroup (which I chair) to explore the feasibility of developing an electronic clinical decision support (CDS) tool that leverages the information and knowledge within the APA’s series of Practice Guidelines, DSM library, and other reference materials. This group will consider the necessary important clinical information sources – such as EHRs, personal health records, health information exchanges, claims and utilization data, patient generated data, mobile health apps, and clinical registries ­– from which to analyze patient-­specific data and produce a set of ranked, evidence­-based, annotated clinical suggestions.

The goal is to develop a CDS tool that is designed in a manner that ultimately benefits patients being treated by primary care practitioners, emergency practitioners, psychiatrists, and other medical specialists who treat patients with mental health and substance use disorders. Tools like this are being developed now in many specialties. Given the vast amount of psychiatric expertise within the APA, as well as the trove of content that exists within the publishing arm of the APA, the opportunity to make this more broadly available to medical practitioners is one that demands consideration.

Such an undertaking would require substantial time and commitment of resources, thus the task of the workgroup is to understand the pros and cons of developing this tool, and to explore its feasibility, including various business models to ensure that this CDS tool becomes a maintainable and sustainable product.

Bringing our expertise to the primary care settings, where most of our patients are treated, should greatly benefit the care of our patients, whether this is through collaborative care, clinical decision support, or telepsychiatry. In the same way that many people with diabetes do not require an endocrinologist, many with mental health conditions do not require a psychiatrist. Yet, primary care practitioners would certainly benefit from more help from us.

I will update readers of this column on our workgroup’s progress at the end of the year.

 

Editors’ Note: The intent of this new column is to discuss topics at the intersection of technology and psychiatry – “Techiatry.” We’ve enlisted two leaders in this field to write for the column. Steven R. Daviss, MD, DFAPA (@HITshrink), is the chief medical informatics officer at M3 Information and chairs the American Psychiatric Association’s Committee on Mental Health Information Technology. James (Jay) H. Shore, MD, MPH, chairs the APA Committee on Telepsychiatry, is director of telemedicine at the Helen & Arthur E. Johnson Depression Center, and an associate professor of psychiatry at the University of Colorado at Denver, Aurora. Email them at [email protected].
 

Medicine is late to the game when it comes to technology, specifically information technology. And psychiatry, even more so. Jay will talk in future columns about early use of telepsychiatry in the 1960s and since. But here in 2016, a surprisingly low percentage of us are using it to deliver care, despite the fact that half of the counties in the United States lack psychiatrists – and telemedicine has been shown to improve access to care.

Nonetheless, telemedicine and other uses of technology across all specialties is growing quickly, as usability, mobile technology, economics, and policy-making all converge. The integration of mental health care (including addiction treatment) with primary care is one of the driving forces in expanding access to the expertise that physicians trained in psychiatry possess. The collaborative care model of integrated care has the most evidence, making regular access to psychiatric consultants a weekly event.

Most people with mental health problems are treated in primary care settings, yet many of those settings are unlikely to use this type of integrated care. What I find most interesting about the collaborative care model is that information is the main currency, not direct patient care. The primary care practitioners and care managers distill known information about their patients, and communicate this information by both story and data to the collaborating psychiatrists. In turn, the psychiatrist assesses the knowledge gaps that could affect their decision making (“Do you know if there is a family history of bipolar disorder?” “Why did she stop the lithium?”) to improve their recommendations to the team.

This exchange of information and knowledge between primary care and psychiatry is being formally incentivized by the Centers for Medicare & Medicaid Services (CMS) with proposed new codes to pay for this exchange, while the American Psychiatric Association has received a large grant from CMS to train 10% of its members in this care model.

Information technology is fundamental to this care model, because the efficient exchange of clinical information is important to optimize the capabilities and comprehensiveness of the clinical decision support provided by the psychiatrist to the primary care team.

As the team members learn what questions are asked and how the consultant arrives at her recommendations, they will become better at making these decisions on their own. They will learn how psychiatrists think and make decisions, weighing other medical, personal, social, family, and logistical aspects to guide the decision making process with the patient.

While this model of care is certainly helpful in expanding access to psychiatric expertise, there are other ways to achieve this access to expert knowledge. One of them is through electronic clinical decision support (CDS) tools. These are tools that apply clinical rules, algorithms, and other knowledge discovery processes to the information within the electronic health record (EHR) about a patient, with the goal of assessing and filling gaps in available patient information so that a set of possible recommendations can be delivered to the clinician.

Knowledge-based CDS tools apply clinical knowledge that comes from practice guidelines, textbooks, and the medical literature to what is known about the patient. The simplest CDS tool might be a rule that says, “IF patient is on lithium for bipolar disorder AND patient has current mood symptoms AND has not had a recent lithium level, THEN check a lithium level.” Applying and coding this rule into an EHR is fairly straightforward. A much more complex CDS tool could help the clinician think through the question, “What should I do next for this 32yo woman with hypertension and moderate depression who is symptomatic?”

Non–knowledge-based CDS tools use machine learning techniques, like neural networks, genetic algorithms, and natural language processing, to “learn” new clinical rules by going through a training process that inputs a large amount of clinical data and uses experts to “train” the system. Such a system was recently developed by IBM Watson and Memorial Sloan-Kettering Cancer Center to aid in developing recommendations for treating oncology patients.

The APA recently formed the CDS Product Workgroup (which I chair) to explore the feasibility of developing an electronic clinical decision support (CDS) tool that leverages the information and knowledge within the APA’s series of Practice Guidelines, DSM library, and other reference materials. This group will consider the necessary important clinical information sources – such as EHRs, personal health records, health information exchanges, claims and utilization data, patient generated data, mobile health apps, and clinical registries ­– from which to analyze patient-­specific data and produce a set of ranked, evidence­-based, annotated clinical suggestions.

The goal is to develop a CDS tool that is designed in a manner that ultimately benefits patients being treated by primary care practitioners, emergency practitioners, psychiatrists, and other medical specialists who treat patients with mental health and substance use disorders. Tools like this are being developed now in many specialties. Given the vast amount of psychiatric expertise within the APA, as well as the trove of content that exists within the publishing arm of the APA, the opportunity to make this more broadly available to medical practitioners is one that demands consideration.

Such an undertaking would require substantial time and commitment of resources, thus the task of the workgroup is to understand the pros and cons of developing this tool, and to explore its feasibility, including various business models to ensure that this CDS tool becomes a maintainable and sustainable product.

Bringing our expertise to the primary care settings, where most of our patients are treated, should greatly benefit the care of our patients, whether this is through collaborative care, clinical decision support, or telepsychiatry. In the same way that many people with diabetes do not require an endocrinologist, many with mental health conditions do not require a psychiatrist. Yet, primary care practitioners would certainly benefit from more help from us.

I will update readers of this column on our workgroup’s progress at the end of the year.