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JAMA Network Insights
March 11, 2020

Managing Virtual Hybrid Psychiatrist-Patient Relationships in a Digital World

Author Affiliations
  • 1Helen and Arthur E. Johnson Depression Center, Department of Psychiatry and Family Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora
  • 2Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora
JAMA Psychiatry. Published online March 11, 2020. doi:10.1001/jamapsychiatry.2020.0139

The rapid technological transformation of society over the past 3 decades has had significant influence on the practice of psychiatry.1 In their personal and professional spheres, psychiatrists now must master relationships across multiple technology platforms and settings. To successfully manage these hybrid physician-patient relationships, psychiatrists need to have an appreciation for the strengths, limitations, and adaptations needed for each technology they use to interface with patients.2

There is a rapidly expanding body of literature informing the use of technology in psychiatric treatment.3 Certain technologies, such as videoconferencing, or telepsychiatry, are long-standing, have a robust evidence base with numerous published clinical guidelines, and have been widely deployed in practice, while for other technologies, the literature is relatively nascent (eg, mobile apps).2,4 The general medical literature provides lessons for addressing ethical and boundary issues arising from technology.5 All psychiatrists should be familiar with technologies in widespread use, or base technologies (eg, email, mobile, electronic health records, videoconferencing), as well as technologies beginning to be more widely adapted, or emerging technologies (eg, patient portals, apps, web-assisted therapy).2 Psychiatrists should develop expertise with, implement, and continuously monitor technology in their practice and make sure to set clear expectations and direction for their patients around the use of technology in clinician-patient interactions. Proffered here is a progressive 3-step framework to evaluate and manage technology in psychiatric practice in the context of these hybrid physician-patient relationships. These components are (1) administrative, (2) operational, and (3) clinical.

Key domains of the administrative components encompass legal, regulatory, and technological requirements. Common considerations across technologies include privacy and security rules (as mandated by federal, state, regulatory bodies, and institutional or organizational policy); technology requirements, such as bandwidth, access, and equipment; and adapting technology to regulatory and malpractice requirements, jurisdiction, and formal or informal processes for patient consent and education.6 The details of these considerations vary widely across technologies and settings. For example, some states require written informed consent for telepsychiatry services (but not for other technologies [eg, text messaging, patient portals, emails, mobile telephones]), while other states do not. These administrative considerations, especially the legal and regulatory standards, set the foundation and structures for operationalizing a technology into practice.

Psychiatrists in solo or group psychiatric practices create the operational components for a technology by accounting for a technology’s administrative considerations, intended use, clinical setting, users, and communication protocols, synthesizing these into a functional construct for clinical use. An enormous range of purposes exist for a technology’s use, including in supporting administration processes, disease and symptom screening, communication, access to care, direct treatment, and treatment augmentation.2,3 Mobile technologies (eg, mobile phones, internet) have rapidly expanded the settings in where care can be delivered from a hospital to an outpatient clinic to a patient’s environment, including at home and in an office. The setting of care has significant influence on how and when care is received, privacy and confidentiality, and clinical processes. Technology can bring additional individuals or users into the clinician-patient dyad, including administrative staff (eg, patient portals), other clinicians (eg, electronic health recordcommunication), family (eg, home-video conferencing), and community (eg, social networking). Media for communication vary widely from traditional face-to-face interaction, ranging from text message or static visual modalities to full interactive video, occurring either synchronously in real time or asynchronously with delays in patient-clinician communication from seconds (eg, text messaging) to days (eg, patient portals). A technology becomes operationalized as it is adapted for intended use based on format and the setting in which it is deployed. The adaptation into clinic settings carries both explicit and implicit rules of conduct between patient and clinician, with considerable potential influence on clinical processes.

Clinicians should seek to understand a technology’s effect on clinical processes in terms of strengths and limitations for monitoring a technology’s effect on rapport, communication and treatment outcomes. For example, live, interactive videoconferencing can create a sense of emotional or virtual distance in patient interactions, particularly during initial meetings, when participants do not have an established relationship. This distance can enhance care for some patients, such as those with a history of trauma or anxiety, giving them a heightened sense of safety and control, especially when conducting videoconferencing in their home environment. For other patients struggling with symptoms of anxiety and isolation, home treatment may increase willingness to engage in care but conversely enable isolation and avoidance by allowing patients to remain at home.7 Clinicians need to assess the best adaption of a technology to a patient’s clinical circumstances in the context of administrative and operational considerations.

This virtual space is a key component of modern physician-patient relationships. What clinicians observe and understand about a patient in virtual space is different across technologies as well as face-to-face interactions. An important component of this is virtual disinhibition, the loosening of social restraints in online vs face-to-face communication. The concept of virtual disinhibition, arising from the literature examining online communication, arguably applies to all technologies.8 By facilitating more unfiltered communication, virtual disinhibition can enhance treatment through providing richer information on a patient’s underlying state but can also create challenges to therapeutic processes and communication. The technology medium of communication can create opportunities for miscommunication (eg, emojis), where meaning and intent may not be shared between the patient and the clinician.9 Psychiatrists need to monitor communication continuously, seeking to err on the side of soliciting clarification and verification of understanding from patients. Developing formal processes for communication with patients is important for maintaining consistent structure as well as boundaries. Several published guidelines describe potential boundary issues for technology and provide recommendations for ethical use in practice.10 Educating patients about technologies used in a specific practice setting along with a discussion of the effect on communication and processes is important before beginning treatment and should be part of an ongoing dialogue. The Table summarizes the 3-component framework for specific technologies in common use.

Table.  Progressive 3-Step Framework’s Key Considerations by Common Technologies
Progressive 3-Step Framework’s Key Considerations by Common Technologies

The technologies of our rapidly evolving digital world provide tremendous promise to enhance psychiatric care through increasing access and information, tailoring care delivery care in a patient’s environment. Psychiatrists need to become adroit at managing hybrid physician-patient relationships by fully understanding the power and the nuances of the tools they use to care for patients.

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Article Information

Corresponding Author: Jay H. Shore, MD, MPH, Centers for American Indian and Alaska Native Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Mail Stop F800, 13055 E 17th Ave, Aurora, CO 80045 (jay.shore@cuanschutz.edu).

Published Online: March 11, 2020. doi:10.1001/jamapsychiatry.2020.0139

Conflict of Interest Disclosures: Dr Shore works with AccessCare, a telebehavioral health services organization, and has received royalties from American Psychiatric Association Publishing and Springer Press.

References
1.
Shore  J.  The evolution and history of telepsychiatry and its impact on psychiatric care: current implications for psychiatrists and psychiatric organizations.  Int Rev Psychiatry. 2015;27(6):469-475. doi:10.3109/09540261.2015.1072086PubMedGoogle ScholarCrossref
2.
Yellowlees  P, Shore  JH.  Telepsychiatry and Health Technologies: A Guide for Mental Health Professionals. American Psychiatric Publishers; 2018.
3.
Hubley  S, Lynch  SB, Schneck  C, Thomas  M, Shore  J.  Review of key telepsychiatry outcomes.  World J Psychiatry. 2016;6(2):269-282. doi:10.5498/wjp.v6.i2.269PubMedGoogle ScholarCrossref
4.
Bashshur  RL, Shannon  GW, Bashshur  N, Yellowlees  PM.  The empirical evidence for telemedicine interventions in mental disorders.  Telemed J E Health. 2016;22(2):87-113. doi:10.1089/tmj.2015.0206PubMedGoogle ScholarCrossref
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Farnan  JM, Snyder Sulmasy  L, Worster  BK, Chaudhry  HJ, Rhyne  JA, Arora  VM; American College of Physicians Ethics, Professionalism and Human Rights Committee; American College of Physicians Council of Associates; Federation of State Medical Boards Special Committee on Ethics and Professionalism*.  Online medical professionalism: patient and public relationships: policy statement from the American College of Physicians and the Federation of State Medical Boards.  Ann Intern Med. 2013;158(8):620-627. doi:10.7326/0003-4819-158-8-201304160-00100PubMedGoogle ScholarCrossref
6.
Shore  JH, Yellowlees  P, Caudill  R,  et al.  Best practices in videoconferencing-based telemental health April 2018.  Telemed J E Health. 2018;24(11):827-832. doi:10.1089/tmj.2018.0237PubMedGoogle ScholarCrossref
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Shore  J, Schneck  C, Mishkind  M, Caudill  R, Thomas  M.  Advancing treatment of depression and mood disorders through innovative models of telepsychiatry.  Focus. In press.Google Scholar
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Suler  J.  The online disinhibition effect.  Cyberpsychol Behav. 2004;7(3):321-326. doi:10.1089/1094931041291295PubMedGoogle ScholarCrossref
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Shore  JH.  Intended and unintended consequence in the digital age of psychiatry: the interface of culture and technology in psychiatric treatments.  Psychiatr Clin North Am. 2019;42(4):659-668.PubMedGoogle ScholarCrossref
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Kind  T.  Professional guidelines for social media use: a starting point.  AMA J Ethics. 2015;17(5):441-447. doi:10.1001/journalofethics.2015.17.5.nlit1-1505PubMedGoogle ScholarCrossref
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