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Background: To examine clinician perspectives on the acceptability, appropriateness/suitability, and feasibility of video telehealth as a way to deliver mental health services during the COVID-19 pandemic. Materials and Methods: Mental health clinicians were surveyed with 27 Likert questions, using previously validated measures, on satisfaction and implementation experience with video telehealth visits between March and June 2020. Results: A total of 112 of 193 clinicians completed the survey (58.0%), including psychiatrists, psychologists, trainees (i.e., residents and fellows), advanced practice providers, and licensed mental health counselors. Clinicians reported high levels of acceptability, feasibility, and appropriateness of video telehealth; they also reported high levels of satisfaction with video telehealth visits. Seventy-nine and a half (79.5%) reported that their patients seemed highly satisfied with video telehealth visits, and 107 (95.5%) of clinicians responded that they would like video telehealth visits to represent at least 25% of their practice in the future. Discussion: Mental health clinicians showed positive attitudes toward the implementation of video telehealth visits, high levels of satisfaction with this care, and indicated strong interest in continuing this modality as a significant portion of clinical practice. Conclusion: This study demonstrates the ability of mental health clinicians to embrace new technology to expand access to care during the COVID-19 pandemic. Results indicate that telemental health is likely to be an integral part of clinic practice in the future.

Objective: Asynchronous telepsychiatry (ATP) is an integrative model of behavioral health service delivery that is applicable in a variety of settings and populations, particularly consultation in primary care. This article outlines the development of a training model for ATP clinician skills. Methods: Clinical and procedural training for ATP clinicians (n = 5) was provided by master's-level, clinical mental health providers developed by three experienced telepsychiatrists (P.Y. D.H., and J.S) and supervised by a tele-psychiatrist (PY, GX, DL) through seminar, case supervision, and case discussions. A training manual and one-on-one sessions were employed for initial training. Unstructured expert discussion and feedback sessions were conducted in the training phase of the study in year 1 and annually thereafter over the remaining 4 years of the study. The notes gathered during those sessions were synthesized into themes to gain a summary of the study telepsychiatrist training recommendations for ATP interviewers. Results: Expert feedback and discussion revealed three overarching themes of recommended skill sets for ATP interviewers: (1) comprehensive skills in brief psychiatric interviewing, (2) adequate knowledge base of behavioral health conditions and therapeutic techniques, and (3) clinical documentation, integrated care/consultation practices, and e-competency skill sets. The model of training and skill requirements from expert feedback sessions included these three skill sets. Technology training recommendations were also identified and included: (1) awareness of privacy/confidentiality for electronic data gathering, storage, management, and sharing; (2) technology troubleshooting; and (3) video filming/retrieval. Conclusions: We describe and provide a suggested training model for the use of ATP integrated behavioral health. The training needs for ATP clinicians were assessed on a limited convenience sample of experts and clinicians, and more rigorous studies of training for ATP and other technology-focused, behavioral health services are needed. Clinical Trials number: NCT03538860.

Objective: Technology is rapidly shifting our day-to-day existence, education, social relationships, health care and business. Psychiatric leaders have slowly explored telepsychiatric services – but few have an approach to technology in general–due to competing clinical, educational and research demands. Technology has typically been added on, rather than integrated, to institutional functions. Method: This narrative review used a literature search of Medline, PsycNET, PsycINFO, Embase, Cochrane, SpringerLink, Scopus, ABI/Inform, Business Source Complete, and Web of Science, using subject headings and keywords along with a manual search of reference lists of articles published by November 2020. The keywords explored four areas: 1) business; 2) service delivery; 3) system change; and 4) technology. Articles were reviewed by title/abstract, full text review and review of references. They were included if they discussed integration of technology into health care and compared literature from medicine/health, psychiatry/behavioral health, business, technology, leadership and health care administration. The goal was to explore how medicine/psychiatry has integrated technology compared to business, and apply business approaches to health care and training. Results: From a total of 2,710 potential references, two authors found 327 eligible for full text review and found 69 papers directly relevant to the concepts. Business and medicine/psychiatry have similarities/differences from both historical and contemporary views. Many health care systems and companies lack a strategic plan for technology and focus only on short-term due to administrative demands. Clinical informatics is a rapidly expanding area and would be central to this process. It has started to facilitate patient-centered care as defined by quality, affordable, and timely health care. While in principle information systems use integrative approaches, electronic health records, electronic means of communications with patients and staff, behavioral health indicators and related digital advances are often added to existing systems rather than integrated. Effective businesses use integrative approaches to share domain knowledge and streamline practices to link information technology (IT) with research and development, production, financing and marketing management. A case example highlights the IT strategy and business leaders’ comments in shifting to straight through processing (STP) from the banking industry for investments. It also exemplifies a model of shared IT-business understanding, which improves performance via efficiency, quality of data/information processing/integration and managerial teamwork. Conclusion: When it is integrated into health care service delivery workflow, evaluated and quality improved, IT facilitates the translation of strategic planning into organizational change. Incremental versus strategically innovative approaches to technological integration for care, education and administration are considered. Successful implementation requires a needs and impact assessment for patients, staff, clinicians and leaders across all levels of the organization. Benefits to the mission, limited disruptions of core operational workflow and reasonable costs reduce the likelihood of failure.

Professional organizations and medical schools need trainees as medical student educators. There are limited data describing the training of residents and fellows as educators. There are also limited data describing the impact of trainee educators on medical student performance and clerkship experience. A narrative literature search was done in PubMed, Embase, and PsychINFO from inception to January 1, 2021, to explore the approaches, methods, and outcomes (e.g., potential benefits) of psychiatric trainees as medical student educators. A total of 630 papers were screened using title and abstract, of which 20 met inclusion criteria. Studies were categorized into four quality tiers based on methodology. Studies described how training programs utilized trainees as student educators, and various methods of teaching instruction. Residents and fellows valued being educators and reported these experiences increased teaching abilities. Medical students rated trainee educators well. Resident-led teaching initiatives were associated with increased exam scores in one study. Data were limited by low survey response rates, qualitative (i.e., subjective) inquiry, and heterogeneity in teaching and training modalities. Due to a lack of high-quality studies, definitive conclusions cannot be drawn about the effectiveness of psychiatry trainees as medical educators nor about how to best train them as educators. Nevertheless, literature suggests that incorporating trainees as educators both augments resident and fellow training and enhances medical student experience and performance. Future research should assess needs and standardize methods, curricula, and outcome measures more systematically.

Sensors and wearables measure physiological and behavioral data in real time for behavioral health, using a variety of methods, interventions, and outcomes. A six-stage scoping review of 10 literature databases focused on keywords in four concept areas: (1) mobile technologies; (2) sensors, wearables, and remote monitoring; (3) mood and anxiety disorders, as well as stress; and (4) behavioral health care. Two authors independently screened results based on titles and abstracts, reviewed the full-text articles, and used inclusion/exclusion criteria to find research that studied self-report or management of symptoms and interventions. Out of a total of 5468 potential references, 76 papers were selected and an additional 16 studies were discovered in references. Of the 92 studies, 54 (58.7%) focused on mood (depressive, N = 28; bipolar, N = 26), 18 (19.6%) on anxiety disorders, and 20 (21.7%) on psychological stress/stress disorders. There were 7 (7.6%) randomized controlled trials, and 31 (33.7%) comparison studies. Research is shifting toward standardized methods, interventions, and evaluation measures, with longitudinal correlation, prediction, and/or biomarking/digital phenotyping of patients’ outcomes. These technologies pose several challenges for users, clinicians (e.g., selection, training, skills), healthcare systems (e.g., technology, integration into workflow, privacy), and organizations (e.g., training, creating a professional e-culture, change). Future research is needed on clinical health outcomes; human–computer interaction; medico-legal, professional, and privacy policy issues; models of service delivery; and effectiveness at a population level, across cultures, and related to economic costs. Clinician and institutional competencies could ensure quality of care, integration of missions, and institutional change.

Objective: Asynchronous technologies such as mobile health, e-mail, e-consult, and social media are being added to in-person and synchronous service delivery. To ensure quality care, clinicians need skills, knowledge, and attitudes related to technology that can be measured. This study sought out competencies for asynchronous technologies and/or an approach to define them. Methods: This 6-stage scoping review of Pubmed/Medline, APA PsycNET, PsycINFO and other databases was based on a broad research question, "What skills are needed for clinicians and trainees to provide quality care using asynchronous technologies for children and adolescents, and how can they be made measurable to implement, teach and evaluate?" The search focused on key words in 4 concept areas: (a) competencies; (b) asynchronous technology; (c) synchronous telepsychiatry, telebehavioral or telemental health; and (d) clinical. The screeners reviewed the full-text articles based on inclusion (mesh of the key words) and exclusion criteria. Results: From a total of 5,877 potential references, 2 authors found 509 eligible for full text review and found 110 articles directly relevant to the concepts. Clinical studies discuss clinical, technical and administrative workflow rather than competencies, though behavioral health professions' position statements advise on adapting care and training. Existing technology competencies for video, social media, mobile health, and other asynchronous technologies were used to build a framework. Training, faculty development, and organizational suggestions are suggested. Conclusions: Research is needed on how to implement and evaluate asynchronous competencies to ensure quality clinical care and training, which is a paradigm shift for participants. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

All health care settings are challenged to provide timely and evidence-based care, particularly for culturally diverse patients with behavioral health disorders. Telepsychiatry and telebehavioral health improve access to care, yet mobile health technologies may have even more promise. A scoping review examined the research question: “What are the components of culturally competent, mobile health care, and what approaches have clinicians and systems taken to implement this care, train clinicians and evaluate outcomes?” The literature search from January 2000 to March 2020 focused on keywords in four concept areas: (1) competencies; (2) mobile health; (3) culture; and (4) clinical care. Of 2471 papers, 183 papers were directly relevant to the concepts. Few studies and professional organizations’ publications specifically discuss skills or competencies for mobile health and cultural factors. Existing telehealth competency sets (i.e., video, social media, mobile health, telebehavioral health, asynchronous) have limited cultural components, and one outline of culturally competencies exists without mention of technology. The landscape of culturally competence is expanded with cultural humility and safety constructs. New sets of mobile health and cultural competencies were constructed—with integration where possible—and training and administrative approaches are suggested. Effectiveness research is needed to implement and evaluate mobile health and cultural competencies. Research is also needed to understand how these competencies align with telehealth, rural health, and unique populations (e.g., refugees, Indigenous peoples, migrant workers, gender diverse groups). Outreach and advocacy for the inclusion of people with lived and living experience is essential to this research.

Sensor, wearable, and remote patient monitoring technologies are typically used in conjunction with video and/or in-person care for a variety of interventions and care outcomes. This scoping review identifies clinical skills (i.e., competencies) needed to ensure quality care and approaches for organizations to implement and evaluate these technologies. The literature search focused on four concept areas: (1) competencies; (2) sensors, wearables, and remote patient monitoring; (3) mobile, asynchronous, and synchronous technologies; and (4) behavioral health. From 2846 potential references, two authors assessed abstracts for 2828 and, full text for 521, with 111 papers directly relevant to the concept areas. These new technologies integrate health, lifestyle, and clinical care, and they contextually change the culture of care and training-with more time for engagement, continuity of experience, and dynamic data for decision-making for both patients and clinicians. This poses challenges for users (e.g., keeping up, education/training, skills) and healthcare organizations. Based on the clinical studies and informed by clinical informatics, video, social media, and mobile health, a framework of competencies is proposed with three learner levels (novice/advanced beginner, competent/proficient, advanced/expert). Examples are provided to apply the competencies to care, and suggestions are offered on curricular methodologies, faculty development, and institutional practices (e-culture, professionalism, change). Some academic health centers and health systems may naturally assume that clinicians and systems are adapting, but clinical, technological, and administrative workflow-much less skill development-lags. Competencies need to be discrete, measurable, implemented, and evaluated to ensure the quality of care and integrate missions.

Asynchronous technologies like mobile health, e-mail, e-consult, and asynchronous video telepsychiatry are effective modes of service delivery to a variety of settings and populations. To ensure quality care, clinicians need skills, knowledge, and attitudes for these technologies. This scoping review was based on the research question, “What skills are needed for clinicians and trainees to provide quality care asynchronously have been published, and how can they be made measurable and reproducible to teach and assess them?” A key word search was done in 9 databases based on five concept areas: (1) competencies; (2) asynchronous technologies; (3) synchronous video; (4) clinical therapeutic relationship; and (5) consultation to primary care. From a total of 4812 potential references, two authors found a total of 86 papers based on inclusion and exclusion criteria. Clinical studies rarely discuss specific skillsets or competencies. Existing publications on video, social media, and mobile health were used to build an asynchronous technology competency set according to the Accreditation Council of Graduate Medical Education framework. Training, faculty development, and administrative changes to service delivery and workplace culture are suggested as part of institutional competencies. Research is needed on how to implement and evaluate asynchronous competencies for clinical care and training as part of organizational change to build a positive e-culture. Research is also needed across cultures and across user’s health, lifestyle, and clinical care experiences.

One possible factor associated with choosing psychiatry as a career is students rating their psychiatry clerkship as excellent. Although this suggests that an excellent clerkship may improve recruitment into psychiatry, to our knowledge there has never been a multi-site survey study of graduating medical students that identify what factors lead to an excellent clerkship rating. The purpose of this study was to determine factors that medical student find important for an excellent psychiatry clerkship experience. A total of 1457 graduating medical students at eight institutions were sent a 22-item Likert-type survey about what clinical and administrative factors they considered when rating their psychiatry clerkship via email in the fall of their last year. 357 (24.5%) responded and Z-test, t-tests, and multiple regression analyses were carried out. The factors which students rated higher than the mean included planned application to psychiatry residency, clear expectations, a transparent grading process, feeling part of a team, timely feedback by faculty, and a competent clerkship coordinator and director. Lectures, active learning, and self-study were rated as less pertinent, and the overall clerkship rating did differ between students going into psychiatry versus other specialties. Although the low response undermines the validity of findings, by improving the administration of the clerkship with clear expectations, grading, feedback, and by encouraging clinical teams to fully integrate students clerkship ratings might improve which could potentially improve recruitment. Future research could further quantify and qualify these parameters and compare psychiatric clerkships to other clerkships.

Author(s): Kinoshita, Shotaro; Cortright, Kelley; Crawford, Allison; Mizuno, Yuya; Yoshida, Kazunari; Hilty, Donald; Guinart, Daniel; Torous, John; Correll, Christoph U; Castle, David J; Rocha, Deyvis; Yang, Yuan; Xiang, Yu-Tao; Kolbaek, Pernille; Dines, David; ElShami, Mohammad; Jain, Prakhar; Kallivayalil, Roy; Solmi, Marco; Favaro, Angela; Veronese, Nicola; Seedat, Soraya; Shin, Sangho; Salazar de Pablo, Gonzalo; Chang, Chun-Hung; Su, Kuan-Pin; Karas, Hakan; Kane, John M; Yellowlees, Peter; Kishimoto, Taishiro | Abstract: BackgroundDuring the COVID-19 pandemic, the use of telemedicine as a way to reduce COVID-19 infections was noted and consequently deregulated. However, the degree of telemedicine regulation varies from country to country, which may alter the widespread use of telemedicine. This study aimed to clarify the telepsychiatry regulations for each collaborating country/region before and during the COVID-19 pandemic.MethodsWe used snowball sampling within a global network of international telepsychiatry experts. Thirty collaborators from 17 different countries/regions responded to a questionnaire on barriers to the use and implementation of telepsychiatric care, including policy factors such as regulations and reimbursement at the end of 2019 and as of May 2020.ResultsThirteen of 17 regions reported a relaxation of regulations due to the pandemic; consequently, all regions surveyed stated that telepsychiatry was now possible within their public healthcare systems. In some regions, restrictions on prescription medications allowed via telepsychiatry were eased, but in 11 of the 17 regions, there were still restrictions on prescribing medications via telepsychiatry. Lower insurance reimbursement amounts for telepsychiatry consultations v. in-person consultations were reevaluated in four regions, and consequently, in 15 regions telepsychiatry services were reimbursed at the same rate (or higher) than in-person consultations during the COVID-19 pandemic.ConclusionsOur results confirm that, due to COVID-19, the majority of countries surveyed are altering telemedicine regulations that had previously restricted the spread of telemedicine. These findings provide information that could guide future policy and regulatory decisions, which facilitate greater scale and spread of telepsychiatry globally.

As the role of technology expands in healthcare, so does the need to support its implementation and integration into the clinic. The concept of a new team member, the digital navigator, able to assume this role is introduced as a solution. With a digital navigator, any clinic today can take advantage of digital health and smartphone tools to augment and expand existing telehealth and face to face care. The role of a digital navigator is suitable as an entry level healthcare role, additional training for an experienced clinician, and well suited to peer specialists. To facilitate the training of digital navigators, we draw upon our experience in creating the role and across health education to introduce a 10-h curriculum designed to train digital navigators across 5 domains: (1) core smartphone skills, (2) basic technology troubleshooting, (3) app evaluation, (4) clinical terminology and data, and (5) engagement techniques. This paper outlines the curricular content, skills, and modules for this training and features a rich online supplementary Appendix with step by step instructions and resources.

The main purpose of research is to investigate questions with value to people (e.g., patients/clients, users of technology), professions, and society at large. Our goal is to test a theory, to elucidate relationships between ideas (e.g., concepts, events), and to contribute to developing knowledge in a field or study. JTiBS “Research in Technology and Behavioral Sciences” is a step toward participating in these processes, as well as a meeting place to discuss ideas. It is meant to complement our authors’ original research and special editions. JTiBS embraces research at the intersection of human behavior, use of technology, and healthcare. We hope this is stimulating good exercise for our minds and a chance to learn about our professions. JTiBS publishes a variety of methodologies (e.g., surveys and questionnaires, randomized controlled trials, direct observation, descriptive methods, laboratory and field experiments, economic analyses, project and program studies, ethnographic analysis, and other studies). If we are not taking action by reading, asking questions, discussing ideas, and researching key questions, we are probably falling behind in today’s world. As we begin to understand issues, we can also increase public awareness and advocate for people and meaningful causes.

Research is increasing on the use of asynchronous technologies like e-mail, text, e-consultation, and asynchronous telepsychiatry by primary care and specialist clinicians. Clinicians need measurable skills, knowledge, and attitudes for these technologies to ensure quality care outcomes. This narrative review used a literature search of Medline, American Psychological Association PsycNET, PsycINFO, Embase, Cochrane, and Web of Science, using subject headings and keywords along with a manual search of reference lists of articles published by December 2019. Articles were included if they discussed and compared asynchronous technologies (e.g., asynchronous telepsychiatry), synchronous telepsychiatric (video including telemental and telebehavioral health), and in-person care. The review compares approaches, effectiveness, skills, and outcomes of these three modes of service delivery in behavioral health and primary care, since those clinicians interface with these technologies. Few studies have evaluated the efficacy and effectiveness of asynchronous technologies in behavioral, or compared them directly to synchronous and in-person care. Publications comparing synchronous telepsychiatry, asynchronous telepsychiatry, and other asynchronous technologies to in-person care focus on the technology used, how to do it, workflow processes, and medico-legal issues, but there is less written about clinical issues like the therapeutic frame, communication, boundaries, and trust. No studies specifically discuss behaviors or competencies for asynchronous care, though telepsychiatric, telebehavioral health, social media, and mobile health competencies have relevant elements. Users of asynchronous technologies (i.e., patients, primary care teams, and psychiatrists) need to adjust clinical skills, work as team members, and integrate technological and administrative factors into workflow. Implications for clinicians, trainees, faculty, administrators, and institutions are discussed. Asynchronous technologies improve access, reduce costs, and compliment other care options. Health systems must appraise how to help individuals and interprofessional participants best interface with a wide range of technologies. This requires adjustments in clinical and administrative workflow. Research in measurable competency sets, implementation, and outcomes is needed.

This scoping review article explores the application of telepresence (TPr), virtual reality (VR), and augmented reality (AR) to clinical care. A literature search of key words was conducted from January 1990 through May 2019 of the following databases: PubMed/Medline, American Psychological Association PsycNET, Pubmed/Medline, Cochrane, Embase, PsycINFO, Web of Science, Scopus, OTSeeker, ABI/INFORM, computer-mediated communication (CMC), technology-mediated communications, Arts & Humanities Citation Index, Project Muse, ProQuest Research Library Plus, Sociological abstracts, Computers and Applied Sciences Complete and IT Source. It focused on concept areas: (1) TPr related to technologies; (2) virtual, augmented, reality, environment; (3) technology or computer-mediated communication; (4) clinical therapeutic relationship (boundaries, care, communication, connect, engagement, empathy, intimacy, trust); (5) telebehavioral health; (6) psychotherapy via technology; and (7) medicine/health care. Inclusion criteria were concept area 1 in combination with 2–7 and 2 or 3 in combination with any of 4–7. From a total of 5214 potential references, the authors found 512 eligible for full-text review and found 85 papers directly relevant to the concepts. From papers’ references and a review of books and popular literature about TPr, virtual reality (VR), and augmented reality (AR), 13 other sources of information were found. The historical evolution of TPr, VR, and AR shows that definitions, foci of studies (e.g., social neuroscience to business), and applications vary; assessments of TPr also vary widely. Studies discuss VR, AR, and TPr in medicine (e.g., rehabilitation, robotics), experimental psychology (laboratory, field, mixed), and behavioral health. Virtual environment (VE) designs aid the study of interpersonal communication and behavior, using standardized social interaction partners, virtual standardized patients, and/or virtual humans—all contingent on the participants’ experience of presence and the ability to engage. Additional research is needed to standardize experimental and clinical interventions, while maintaining ecological validity. Technology can significantly improve quality of care, access to new treatments and training, if ethical and reimbursement issues are better explored.

We continue to increase our exchange of information through health technologies, used to access, disseminate, and analyze information. Clinical informatics is a rapidly expanding area and facilitates patient-centered care as defined by quality, affordability, and timely health care. This chapter covers developments in information systems, electronic health records, electronic communications with patients and staff (e.g., alerts, texts), behavioral health indicators and related digital advances to improve practice and research. The reader can learn how to set goals toward quality outcomes and be efficient while remaining patient-centered using technology, and adapt to technological components and processes used by systems. By grasping how systems are designed and tailored to collect data, clinicians can use technology to inform decisions and facilitate outcomes. Setting priorities involves input from all care participants, as well as technological competencies for the clinician and institutional/organizational. Patient, clinician, and institutional competencies for skills, attitudes, and behaviors can align clinical care, training, and research missions and stimulate quality improvement.

Health education has seen a surge of interest in active learning strategies like the flipped classroom. In response to the need for physical distancing in the age of COVID-19, schools are rapidly shifting to web-based and video technology, sometimes without being able to predict the outcomes of this change. The objectives of this pilot experiment were to (1) compare active learning (AL) methods versus traditional lecture for transmitting and retaining knowledge in the introductory pre-clinical medical school curriculum and (2) weigh whether the costs required to flip instruction were justified by learning gains. The authors took a 2 h lecture for first-year medical students and converted half of it into an AL format. In-person lecture and active learning groups were compared in terms of student knowledge at pre-intervention, immediately post-intervention, and 6months post-intervention. Costs for first-time delivery and anticipated costs for repeat delivery of each format were calculated. Students' gains in knowledge increased in both groups, though more by lecture (control) than via AL. Delivering a single hour of new AL costs 3.4 times that of a new lecture. Repeat offerings of the AL intervention were estimated to cost 5.4 times that of the repeat lecture. The 1 h AL session was less effective than the 1 h lecture for knowledge acquisition and retention at 6-month follow-up. The AL was more expensive to produce and to repeat. Future research needs to evaluate the impact of AL with a larger N, control group, structured faculty/resident procedures, and assessment of gaining and applying attitudes and skills in addition to knowledge.

Background Video and other technologies are reshaping the delivery of health care, yet barriers related to workflow and possible provider fatigue suggest that a thorough evaluation is needed for quality and process improvement. Objective This scoping review explored the relationship among technology, fatigue, and health care to improve the conditions for providers. Methods A 6-stage scoping review of literature (from 10 databases) published from 2000 to 2020 that focused on technology, health care, and fatigue was conducted. Technologies included synchronous video, telephone, informatics systems, asynchronous wearable sensors, and mobile health devices for health care in 4 concept areas related to provider experience: behavioral, cognitive, emotional, and physical impact; workplace at the individual, clinic, hospital, and system or organizational levels; well-being, burnout, and stress; and perceptions regarding technology. Qualitative content, discourse, and framework analyses were used to thematically analyze data for developing a spectrum of health to risk of fatigue to manifestations of burnout. Results Of the 4221 potential literature references, 202 (4.79%) were duplicates, and our review of the titles and abstracts of 4019 (95.21%) found that 3837 (90.9%) were irrelevant. A full-text review of 182 studies revealed that 12 (6.6%) studies met all the criteria related to technology, health care, and fatigue, and these studied the behavioral, emotional, cognitive, and physical impact of workflow at the individual, hospital, and system or organizational levels. Video and electronic health record use has been associated with physical eye fatigue; neck pain; stress; tiredness; and behavioral impacts related to additional effort owing to barriers, trouble with engagement, emotional wear and tear and exhaustion, cognitive inattention, effort, expecting problems, multitasking and workload, and emotional experiences (eg, anger, irritability, stress, and concern about well-being). An additional 14 studies that evaluated behavioral, emotional, and cognitive impacts without focusing on fatigue found high user ratings on data quality, accuracy, and processing but low satisfaction with clerical tasks, the effort required in work, and interruptions costing time, resulting in more errors, stress, and frustration. Our qualitative analysis suggests a spectrum from health to risk and provides an outline of organizational approaches to human factors and technology in health care. Business, occupational health, human factors, and well-being literature have not studied technology fatigue and burnout; however, their findings help contextualize technology-based fatigue to suggest guidelines. Few studies were found to contextually evaluate differences according to health professions and practice contexts. Conclusions Health care systems need to evaluate the impact of technology in accordance with the Quadruple Aim to support providers’ well-being and prevent workload burden, fatigue, and burnout. Implementation and effectiveness approaches and a multilevel approach with objective measures for clinical, human factors, training, professional development, and administrative workflow are suggested. This requires institutional strategies and competencies to integrate health care quality, technology and well-being outcomes.

BACKGROUND Video and other technologies are reshaping the delivery of health care, yet barriers related to workflow and possible provider fatigue suggest that a thorough evaluation is needed for quality and process improvement. OBJECTIVE This scoping review explored the relationship among technology, fatigue, and health care to improve the conditions for providers. METHODS A 6-stage scoping review of literature (from 10 databases) published from 2000 to 2020 that focused on technology, health care, and fatigue was conducted. Technologies included synchronous video, telephone, informatics systems, asynchronous wearable sensors, and mobile health devices for health care in 4 concept areas related to provider experience: behavioral, cognitive, emotional, and physical impact; workplace at the individual, clinic, hospital, and system or organizational levels; well-being, burnout, and stress; and perceptions regarding technology. Qualitative content, discourse, and framework analyses were used to thematically analyze data for developing a spectrum of health to risk of fatigue to manifestations of burnout. RESULTS Of the 4221 potential literature references, 202 (4.79%) were duplicates, and our review of the titles and abstracts of 4019 (95.21%) found that 3837 (90.9%) were irrelevant. A full-text review of 182 studies revealed that 12 (6.6%) studies met all the criteria related to technology, health care, and fatigue, and these studied the behavioral, emotional, cognitive, and physical impact of workflow at the individual, hospital, and system or organizational levels. Video and electronic health record use has been associated with physical eye fatigue; neck pain; stress; tiredness; and behavioral impacts related to additional effort owing to barriers, trouble with engagement, emotional wear and tear and exhaustion, cognitive inattention, effort, expecting problems, multitasking and workload, and emotional experiences (eg, anger, irritability, stress, and concern about well-being). An additional 14 studies that evaluated behavioral, emotional, and cognitive impacts without focusing on fatigue found high user ratings on data quality, accuracy, and processing but low satisfaction with clerical tasks, the effort required in work, and interruptions costing time, resulting in more errors, stress, and frustration. Our qualitative analysis suggests a spectrum from health to risk and provides an outline of organizational approaches to human factors and technology in health care. Business, occupational health, human factors, and well-being literature have not studied technology fatigue and burnout; however, their findings help contextualize technology-based fatigue to suggest guidelines. Few studies were found to contextually evaluate differences according to health professions and practice contexts. CONCLUSIONS Health care systems need to evaluate the impact of technology in accordance with the Quadruple Aim to support providers’ well-being and prevent workload burden, fatigue, and burnout. Implementation and effectiveness approaches and a multilevel approach with objective measures for clinical, human factors, training, professional development, and administrative workflow are suggested. This requires institutional strategies and competencies to integrate health care quality, technology and well-being outcomes.

Purpose of Review The COVID-19 pandemic has impacted lives globally, posing unique challenges to mental health services exposing vulnerability and limitations within these systems. During the course of the pandemic, telecommunications technologies (e-mental health care) have served a critical role in psychiatric care. It is important to understand current lessons learned in e-mental health care and implications for global mental health systems for both emerging from the pandemic and after the pandemic has ended. Recent Findings There are significant regulatory, policy, and evaluation challenges for global e-mental health impacting patients, clinicians, health systems, and decision-makers. These include complex regulatory issues, difficulties of providing care across boundaries, and keeping pace with the implementation of new technologies in behavioral health. Summary The collaborative development of global standards along with policies, appropriate regulations, and developing new models of research and development opens the possibility of improved access to care across national boundaries.

Faculty and trainees need clinical skills, knowledge, and attitudes to ensure quality care using technology. Clinical faculty teach, supervise, and role model skills for trainees and interprofessional team members. Mobile health, smartphone/device, and app competencies may be situated within the graduate medical education milestone domains. This article outlines these competencies and aligns them with clinical care, teaching methods, and evaluation. These competencies have similarities and differences from in-person and telepsychiatric care and additional dimensions like clinical decision support, technology selection, and information flow management across an e-platform. Health systems must integrate in-person and technology-based care, while maintaining the therapeutic relationship.

Projects done in interprofessional groups can foster faculty development with minimal resources beyond what is already available at the university or medical center. Each project can yield multiple "wins" in individual faculty growth while meeting the needs of academic medical centers. These projects can build collaborative skills and a sense of community among faculty, trainees, and staff. The combination of low costs, high yields, and improvements in team skills make these approaches appealing and sustainable in resource-constrained medical centers. The authors describe 4 sample projects and their teams, needed resources, and outcomes.

In the ever-changing fields of health care, continuing professional development (CPD) and lifelong learning are essential for patient care, regulatory requirements, personal growth, and job satisfaction. However, no specific systems in approaching CPD have been delineated, and most health professionals are left to their own devices to manage it, on top of all their other professional responsibilities. This article (1) outlines the importance of CPD, (2) describes potential systematic approaches to CPD and potential ways to assess their effectiveness, and (3) reviews resources available to incorporate into a systematic approach.

The use of interprofessional health profession education and training (IPE) has been repeatedly identified as a means for developing greater integration and more effective health care. This paper advocates for greater IPE for telebehavioral health care professionals during graduate school, supervised experience, and independent practice. The authors propose that this can be achieved by using the recently developed interprofessional telebehavioral (TBH) competencies as a framework to organize and provide TBH education and training. Major identified barriers to IPE for TBH include professional centrism, exclusive education and training experiences, and lack of experience and training in interdisciplinary TBH teams. Proposed alternatives to promote IPE TBH include increased collaboration in educational experiences across disciplines, use of inclusive TBH training models and rotations for skills and attitudes, development of IPE TBH teams with an emphasis on competencies, and linking TBH institutional infrastructure across organizations and professions.

Technologies like smartphones and apps are reshaping life, health care, and business. Clinicians need skills, knowledge, and attitudes to ensure quality care and to supervise the current generation of trainees, consistent with the Institute of Medicine’s Health Professions Educational Summit. Literature is integrated on patient-, learner-, competency-, and outcome-based themes from the fields of technology, health care, pedagogy, and business. Mobile health, smartphone/device, and app competencies are organized in the Accreditation Council for Graduate Medical Education (ACGME) Milestone domains of patient care, medical knowledge, practice-based learning and improvement, systems-based practice, professionalism, and interpersonal skills and communication. Teaching methods are suggested to align competency outcomes, learning context, and evaluation. Services by mobile health, smartphone/device, and apps have a broader scope than in-person and telehealth and telebehavioral health care. This includes clinical decision support in medicine, hybrid delivery, and integration across health systems’ e-platforms. A curriculum with seminar, case- and problem-based teaching, supervision, evaluation, and quality improvement practices is needed to achieve competency outcomes. Clinicians have to adjust assessment, triage and treatment and attend to ethical, privacy, security, and other challenges. Health systems need to manage change, proactively plan faculty development, and create a positive e-culture for learning. Research is needed on implementing and evaluating mobile health competencies for this significant paradigm shift in health care.

(Reprinted with permission from Am J Psychiatry 2018; 175:86–90)

The effectiveness of telepsychiatry video for clinical care is well established, and clinician and psychiatry resident interest in it is growing—particularly in light of the COVID-19 impact. Still, few residency programs in the United States have core curricula, rotations/electives available, and competencies, and many faculty have no experience. A survey was sent via national organization listserves for residents, fellows, faculty, and program directors to complete. The survey queried demographics, clinical experience and interest, and views/concerns, using Likert-like and yes/no questions. Descriptive statistics and other analyses compared the groups to assess impact of clinical experience on interest and views/concerns. Respondents (N = 270) have limited clinical experience with telepsychiatry (46% none), with trainees having less than others, and yet, most were very interested or interested in it (68%). Trainees (N = 123) have concerns about being prepared for future practice. Clinical experience with video in the range of 6–20 h appears to dramatically increase interest and reduce concerns, though less time has a positive effect. Respondents have concerns about connectivity, medico-legal issues, and clinical effectiveness (e.g., diverse populations, psychosis, and emergencies) with telepsychiatry. More research is needed to assess current clinical and curricular experience, interest, and concerns. Additional curricular interventions during residency and fellowship training could build skills and confidence, if this is feasible, and the benefits outweigh the costs.

Background Due to rapidly increasing rates of COVID-19 across the country, system-wide changes were needed to protect the health and safety of health care providers and consumers alike. Technology-based care has received buy-in from all participants, and the need for technological assistance has been prioritized. Objective The objective of this study was to determine the initial perceptions and experiences of interprofessional behavioral health providers about shifting from traditional face-to-face care to virtual technologies (telephonic and televideo) during the COVID-19 pandemic. Methods A survey-based study was performed at a large, integrated medical health care system in West-Central Florida that rapidly implemented primary care provision via telephone and televideo as of March 18, 2020. A 23-item anonymous survey based on a 7-point Likert scale was developed to determine health care providers’ perceptions about telephonic and televideo care. The survey took 10 minutes to complete and was administered to 280 professionals between April 27 and May 11, 2020. Results In all, 170 respondents completed the survey in entirety, among which 78.8% (134/170) of the respondents were female and primarily aged 36-55 years (89/170, 52.4%). A majority of the respondents were outpatient-based providers (159/170, 93.5%), including psychiatrists, therapists, counselors, and advanced practice nurses. Most of them (144/170, 84.7%) had used televideo for less than 1 year; they felt comfortable and satisfied with either telephonic or televideo mode and that they were able to meet the patients’ needs. Conclusions Our survey findings suggest that health care providers valued televideo visits equally or preferred them more than telephonic visits in the domains of quality of care, technology performance, satisfaction of technology, and user acceptance.

Objective To report the clinical characteristics and transmission rate of coronavirus disease 2019 (COVID-19) in a community inpatient long-term care psychiatric rehabilitation facility designed for persons with serious mental illness to provide insight into transmission and symptom patterns and emerging testing protocols, as well as medical complications and prognosis. Methods This study examined a cohort of 54 residents of a long-term care psychiatric rehabilitation program from March to April 2020. Baseline demographics, clinical diagnoses, and vital signs were examined to look for statistical differences between positive versus negative severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) groups. During the early phase of the pandemic, the facility closely followed the local shelter-in-place order (starting March 19, 2020) and symptom-based testing. Results Of the residents, the primary psychiatric diagnoses were schizoaffective disorder: 28 (51.9%), schizophrenia: 21 (38.9%), bipolar I disorder: 3 (5.5%), and unspecified psychotic disorder: 2 (3.7%). Forty (74%) of 54 residents tested positive for SARS-COV-2, with a doubling time of 3.9 days. There were no statistical differences between the positive SARS-COV-2 versus negative groups for age or race/ethnicity. Psychiatric and medical conditions were not significantly associated with contracting SARS-COV-2, with the exception of obesity (n = 17 [43%] positive vs n = 12 [86%] negative, P = .01). Medical monitoring of vital signs and symptoms did not lead to earlier detection. All of the residents completely recovered, with the last resident no longer showing any symptoms 24 days from the index case. Conclusion Research is needed to determine optimal strategies for long-term care mental health settings that incorporate frequent testing and personal protective equipment use to prevent rapid transmission of SARS-COV-2.

Professional organizations and medical schools need trainees as medical student educators. There are limited data describing the training of residents and fellows as educators. There are also limited data describing the impact of trainee educators on medical student performance and clerkship experience.A narrative literature search was done in PubMed, Embase, and PsychINFO from inception to January 1, 2021, to explore the approaches, methods, and outcomes (e.g., potential benefits) of psychiatric trainees as medical student educators. A total of 630 papers were screened using title and abstract, of which 20 met inclusion criteria. Studies were categorized into four quality tiers based on methodology.Studies described how training programs utilized trainees as student educators, and various methods of teaching instruction. Residents and fellows valued being educators and reported these experiences increased teaching abilities. Medical students rated trainee educators well. Resident-led teaching initiatives were associated with increased exam scores in one study. Data were limited by low survey response rates, qualitative (i.e., subjective) inquiry, and heterogeneity in teaching and training modalities.Due to a lack of high-quality studies, definitive conclusions cannot be drawn about the effectiveness of psychiatry trainees as medical educators nor about how to best train them as educators. Nevertheless, literature suggests that incorporating trainees as educators both augments resident and fellow training and enhances medical student experience and performance. Future research should assess needs and standardize methods, curricula, and outcome measures more systematically.

BACKGROUND Asynchronous telepsychiatry (ATP; delayed-time) consultations are a novel form of psychiatric consultation in primary care settings. Longitudinal studies comparing clinical outcomes for ATP with synchronous telepsychiatry (STP) are lacking. OBJECTIVE This study aims to determine the effectiveness of ATP in improving clinical outcomes in English- and Spanish-speaking primary care patients compared with STP, the telepsychiatry usual care method. METHODS Overall, 36 primary care physicians from 3 primary care clinics referred a heterogeneous sample of 401 treatment-seeking adult patients with nonurgent psychiatric disorders. A total of 184 (94 ATP and 90 STP) English- and Spanish-speaking participants (36/184, 19.6% Hispanic) were enrolled and randomized, and 160 (80 ATP and 80 STP) of them completed baseline evaluations. Patients were treated by their primary care physicians using a collaborative care model in consultation with the University of California Davis Health telepsychiatrists, who consulted with patients every 6 months for up to 2 years using ATP or STP. Primary outcomes (the clinician-rated Clinical Global Impressions [CGI] scale and the Global Assessment of Functioning [GAF]) and secondary outcomes (patients’ self-reported physical and mental health and depression) outcomes were assessed every 6 months. RESULTS For clinician-rated primary outcomes, ATP did not promote greater improvement than STP at 6-month follow-up (ATP vs STP, adjusted difference in follow-up at 6 months vs baseline differences for CGI: 0.2, 95% CI −0.2 to 0.6; P=.28; and GAF: −0.6, 95% CI −3.1 to 1.9; P=.66) or 12-month follow-up (ATP vs STP, adjusted difference in follow-up at 12 months vs baseline differences for CGI: 0.4, 95% CI −0.04 to 0.8; P=.07; and GAF: −0.5, 95% CI −3.3 to 2.2; P=.70), but patients in both arms had statistically and clinically significant improvements in both outcomes. There were no significant differences in improvement from baseline between ATP and STP on any patient self-reported ratings at any follow-up (all P values were between .17 and .96). Dropout rates were higher than predicted but similar between the 2 arms. Of those with baseline visits, 46.8% (75/160) did not have a follow-up at 1 year, and 72.7% (107/147) did not have a follow-up at 2 years. No serious adverse events were associated with the intervention. CONCLUSIONS This is the first longitudinal study to demonstrate that ATP can improve clinical outcomes in English- and Spanish-speaking primary care patients. Although we did not find evidence that ATP is superior to STP in improving clinical outcomes, it is potentially a key part of stepped mental health interventions available in primary care. ATP presents a possible solution to the workforce shortage of psychiatrists and a strategy for improving existing systems of care. CLINICALTRIAL ClinicalTrials.gov NCT02084979; https://clinicaltrials.gov/ct2/show/NCT02084979.

Telepsychiatry’s effectiveness is well established, and interest in it is growing, despite few residency/fellowship core curricula and rotations. A link to a cross-sectional survey was sent via national organization listservs for psychiatry residents, fellows, faculty, and program directors to complete. The survey queried demographics, clinical experience, and views/concerns about telepsychiatry. Descriptive statistics and other analyses compared groups to assess the impact of amount clinical experience and psychiatric specialty (general vs. child and adolescent psychiatry), on interest, and views/concerns about the practice of telepsychiatry. All respondents (N = 270; child psychiatry N = 89) have limited clinical experience with telepsychiatry (46% overall; 49% of non-child had none versus 40% child). Trainees (N = 123; child N = 43) expressed less interest than others. All respondents expressed worry about ability to do a physical exam, connectivity, medico-legal issues, and fit for diverse populations. Child respondents expressed less concern than others, but they reported more worry about loss of nonverbal cues. Clinical experience with telepsychiatry in the range of 6–20 h appears to build interest and allay concerns, though 1–5 h also may have a positive impact. More research is needed to assess clinical experience, interest, and concerns for adult and child psychiatry trainees and clinicians. Replicable, curricular interventions appear to be indicated.