Technologies Used for Clinical Care, Part I: Introduction and Telecompetencies

Overview

This blog focuses on telepsychiatry and other technologies for clinical care and training—it emphasizes effective models and a range of technologies, along with competencies for video, social media, and mobile health. See next month’s blog, Part II, which focuses on clinical and administrative issues and challenges.

Introduction

A new range of technologies challenges clinicians, trainees, and educators to ensure high-quality clinical care, professional standards, and sensitivity to differences in participants 1. We are moving from synchronous telepsychiatry (TP) or telebehavioral health (i.e., video) – a term inclusive of other disciplines and used rather than telemental health to be inclusive of addiction care – leverages care for diagnosis/assessment, consultation, and a range of treatments. It has been used in many populations (e.g., adult, child, geriatric), cultures and settings (e.g., primary care) (2). TP outcomes are comparable to in-person care and it has been used with a variety of models of care (i.e., collaborative care) 2-3.

Indeed, the profession has to consider new applications of technology as instrumental, rather than supplemental, to practice and teaching (e.g., “instructional technology”), as technology is reshaping clinical care, education, and everyday life. A spectrum is suggested to unify what the person/patient seeks from technology on her/his own all the way to formal medical services via telepsychiatry – putting the reader in the person’s/patient’s perspective. The spectrum also moves from low to high engagement and technology requirements: website information; support/chat groups; social media; formal educational materials; resources for self-directed assessment; assisted self-assessment and care; asynchronous patient-clinician (i.e., mH app, text or e-mail); synchronous video TP; and hybrid care (i.e., in-person and/or technology combinations 1.

Telecompetencies

Telecompetencies are becoming an essential part of the clinical toolkit skills and practices. Competencies are targeted with clinical outcomes and supported by teaching/supervisory methods, evaluation, and feedback by faculty clinicians. These include telepsychiatric competencies 4-5 and also telebehavioral health competencies across mental health specialties 6. Such domains include: clinical evaluation and care; administration; cultural competence and diversity; legal and regulatory issues; evidence-based and ethical practice; and mobile health, smartphone, and apps 6.

Competencies are a focus of undergraduate and graduate medical education but have yet to be fully described in the continuing medical education (CME) realm. The Institute of Medicine and its Health Professions Education Summit 7-8 linked health care professional training with quality of care, safety, and interdisciplinary skill objectives for patient-centered care, interdisciplinary teams, evidence-based practice, and information technology (IT). Another consideration is that lifelong learning is an ongoing necessary process for all psychiatrists – as supported by the American Board of Psychiatry and Neurology (ABPN), and the American Psychiatric Association, based on a lifelong learning platform 9. CME still lacks an integrated plan of competencies, despite consensus- and evidence-based guidelines and accreditation, legal, and regulatory agency policies. There are many professionalism implications for practice and education 10.

Telepsychiatric competencies have been updated 4-5 to include medication prescribing. They are based on the Accreditation Council for Graduate Medical Education (ACGME) domains of patient care, medical knowledge, practice based learning and improvement, systems based practice, professionalism, and interpersonal skills and communication domains 11. These competencies adapted the Dreyfus model for learners (5 levels: Novice, Advanced, Competent, Proficient, and Expert) 12, but combined them into Novice/Advanced Beginner, Competent/Proficient, and Expert levels. Telecompetencies are also being applied to underserved, primary care, and integrated care populations 13-16 also look at tele-behavioral health in collaborative and integrated care.

Social media 17-18 and mH 19-20 competencies have been published for clinical care that is asynchronous not synchronous, so workflow is not structured like a traditional care visit or daytime hours. If conducted over public sites and systems, privacy and security may be difficult, if not impossible. When clinicians use a single smartphone, personal and professional experiences overlap, and receiving/sending texts may be problematic after hours, similar to the answering e-mail to patients in the evening. Faculty are challenged to develop attitudes and to supervise “in-time” with the informal “24-hour, 7 day per week” workflow. Systems have had to deal with professionalism, medico-legal, and workflow integration issues.

mH has an increasing role in health care, with technology components for monitoring, alerting, data collection, record maintenance, detection and prevention of problems 21. The mH architecture has operational features of accessibility, timeliness, and integration. mH has remarkable options for integrating care across settings, offering connectivity to meet patient needs and facilitating clinical decision-making (i.e., clinical decision support (CDS) 16. It provides clinicians and others with knowledge and patient-specific information, intelligently filtered and/or presented at appropriate times, to enhance health and healthcare 22. This improves patient outcomes, reduces unnecessary mistakes and expenses, and increases efficiency 23. For example, a clinician and patient could decide to use one to monitor habits (e.g., smoking), mood changes (i.e., depression), level of activity and vital signs (e.g., blood pressure). The data could be texted to the clinician, though it is better when funneled into the EHR to notes and map trends temporally and trigger the clinician if a markedly abnormal reading is noted.

The collection of data in the patient’s day-to-day life is called ecological momentary assessment (EMA) and it involves repeated sampling of naturalistic behaviors and experiences 24-25. Technology methods have evolved from paper-and-pencil diary methods (e.g., medication calendars) to signal- and event-dependent reporting. Signal-dependent reporting has the patient report on symptoms at random intervals during the day in response to an alarm. For event-dependent reporting, the patient reports on symptoms after predetermined interpersonal or challenging events during the day. These demand a level of engagement and motivation that may exceed the capacity of some participants, but newer smartphones and wearable sensors are less intensive and capture an accurate picture of a patient’s symptoms in real time. Changes in mood/affect therefore correlate better with clinician-rated affective symptoms and subsequent risk of suicidal ideation in bipolar patients 1.

About the Author

Donald M. Hilty, M.D., M.B.A., is a member of APA’s Committee on Telepsychiatry as is Associate Chief of Staff, VA Northern California Health Care System.

References

  1. Hilty DM, Chan S, Torous J, et al. New frontiers in healthcare and technology: Internet- and web-based mental options emerge to complement in-person and telepsychiatric care options. J Health Med Informatics. 2015;6(4):1-14.
  2. Hilty DM, Ferrer D, Parish MB, et al. The effectiveness of telemental health: A 2013 review. Tel J E-Health. 2013;19(6):444-54.
  3. Hilty DM, Rabinowitz TR, McCarron RM, et al. An update on telepsychiatry and how it can leverage collaborative, stepped, and integrated services to primary care. Psychosomatics. 2017
  4. Hilty DM, Crawford A, Teshima J, et al. A framework for telepsychiatric training and e-health: competency-based education, evaluation and implications. Int Rev Psychiatry. 2015;27:569-92.
  5. Hilty DM, Maheu M, Drude, K, et al. The need to implement and evaluate telehealth Acad Psychiatr. 2018;42(6):818-24.
  6. Maheu M, Drude K, Hertlein KM, et al, A framework for telebehavioral health competencies across professions: Process, outcome and practice considerations in a complex era of healthcare. Acad Psychiatr. 2018;42(6):825-33.
  7. Institute of Medicine, 2003. Health Professions Education Summit.
  8. Institute of Medicine. The Core Competencies Needed for Health Care Professionals. Health Professions Education: A Bridge to Quality. Washington, DC: The National Academies Press. doi: 10.17226/10681, pp. 45, 2003.
  9. American Psychiatric Association Council on Medical Education and Lifelong Learning. (2014). Training Psychiatrists for Integrated Behavioral Health Care (Official Actions). Arlington, VA: American Psychiatric Association.
  10. DeJong S. Professionalism and technology: Competencies across the tele-behavioral health and e-behavioral health spectrum. Acad Psychiatry. 2018;42(6):800-7.
  11. Accreditation Council on Graduate Medical Education. (2013). Common Program Requirements.
  12. Dreyfus SE, Dreyfus HL. A five-stage model of the mental activities involved in directed skill acquisition. Berkeley, CA: University of California, Operations Research Center, 1980.
  13. Crawford A, Gratzer D, Jovanovic M, et al. Building ehealth and telepsychiatry capabilities: three educational reports across the learning continuum. Acad Psychiatry. 2018;42(6):852-6.
  14. Ratzliff A, Sunderji N, McCarron R. Tele-behavioral health in collaborative and integrated care: Competencies for psychiatric trainees, faculty and community providers. Acad Psychiatry. 2018;42(6):834-40.
  15. Sunderji N, Ion A, Huynh D, et al. Advancing integrated care through psychiatric workforce development: A systematic review of educational interventions to train psychiatrists in integrated care. Can J Psychiatry. 2018;63(8):513-25.
  16. Hilty DM, Sunderji N, Suo S, et al. Telepsychiatry/telebehavioral health and integrated care: evidence-base, best practice models and competencies. Int Rev Psychiatry, In Press
  17. Hilty DM, Zalpuri I, Stubbe D, et al. Social media/networking as part of e-behavioral health and psychiatric education: competencies, teaching methods, and implications. J Technology in Behav Sci. 2018 doi 10.1007/s41347-018-0061-7.
  18. Zalpuri I, Liu H, Stubbe D, et al. Social media and networking competencies for psychiatric education: skills, teaching methods, and implications. Acad Psychiatry. 2018;42(6):808-17.
  19. Hilty DM Chan S, T. Hwang T, et al. Advances in mobile mental health: opportunities and implications for spectrum of e-mental health services. mHealth. 2017;21;3:34. doi: 10.21037/mhealth.2017.06.02.
  20. Hilty DM, Chan S, Torous J, et al. A competency-based framework for psych/behavioral health apps for trainees, faculty, programs and health systems. Psych Clin N Amer. 2018. In Press
  21. Silva BMC, Rodrigues JPC, de la Torre I, et al. Mobile-health: A review of current state in 2015. Journal of Biomedical Informatics. 2015;56:265-72.
  22. Osheroff JA, Teichc JM, Middletone B, et al. A roadmap for national action on clinical decision support. Journal of the American Medical Informatics Association. 2007;141-5.
  23. Kawamoto K, Houlihan CA, Balas EA, et al. Improving clinical practice using clinical decision support systems: A systematic review of trials to identify features critical to success. British Medical Journal. 2005;330(7494),765. Epub 2005 Mar 14.
  24. Carlson EB, Field NP, Ruzek JI, et al. Advantages and psychometric validation of proximal intensive assessments of patient-reported outcomes collected in daily life. Quality of Life Research. 2016;25:507-16.
  25. van Os J, Delespaul P, Barge D, et al. Testing an mHealth momentary assessment Routine Outcome Monitoring application: A focus on restoration of daily life positive mood states. PLoS One. 2014;16;9(12):e115254. doi: 10.1371/journal.pone.0115254. eCollection 2014.

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