TECHNOLOGY IN EXPOSURE How Scottie Beams Us Up, And Other Clinical Applications Sara Smucker Barnwell, PHD April 10, 2015
Welcome
Your presenter Sara Smucker Barnwell, PhD Offers telemental health training across disciplines Provides technology enabled exposure in private practice and institutional settings Appointment at UW, former VA provider Committees on telehealth, technology MAL SSB 2014
Agenda Definitions, practical examples Telephone, videoconferencing technologies in exposure Mobile applications, mobile monitoring in exposure Virtual Reality in exposure Regulation, guidelines and ethics for technology use Practical considerations
Disclaimers* During a technology presentation, technology will generally always fail Offer best practice recommendations based on clinical work, literature review and regulatory experience Aim to offer guidance in a developing area Always review state regulations Consult with your own legal counsel Not legal advice nor clinical advice *The digital fine print MAL SSB 2014
Disclosure Consultant with Virtually Better, Inc. WSPA Telehealth Committee MAL SSB 2014
Definitions and Examples
Jargon!
Operational definitions Telecommunications Technology: Telecommunications is the preparation, transmission, communication, or related processing of information by electrical, electromagnetic, electromechanical, electrooptical, or electronic means (Committee on National Security Systems, 2010) MAL SSB 2014
Exposure is a clinical tool
Operational definitions Videoconferencing: Real-time, generally two way transmission of digitized video images between multiple locations; uses telecommunications to bring people at physically distinct locations together for meetings. Each individual location in a videoconferencing system requires a room equipped to send and receive video (ATA, 2009)
Operational definitions Mobile Device: Handheld computing device made for portability Often web enabled Diversity of functions (e.g., telephony, computing, Internet) Diversity of platforms (e.g., Apple, Google/ Android, Windows)
Operational definitions Mobile Application: Application software designed to run on smartphone, tablet or other mobile device. Specific to device platform (iphone/ipad, Android, Blackberry, etc.)
Operational definitions Virtual Reality: Immersive multimedia/ computer generated environment that simulates physical presence in environments real or imagined Can recreate taste, sight, sound, smell touch Currently available in over 60 VA hospitals, clinics, affiliated medical centers and university clinics (ICT, 2014)
Operational definitions Virtual Reality: Can involve large-scale immersion (e.g., light stage, body sensors, that of equipment to simulate diversity of movements, smells tastes) Can involve small scale application (e.g., adaptation of a mobile device Head mounted displays vs. immersive technological environments
Operational definitions
Moving up the SUDS hierarchy SSB 2015
Exposure Based Therapies
What is it Exposure therapies: Psychotherapy technique for anxiety-spectrum disorders Planful exposure to feared stimuli Predicated on concept of desensitization and successive approximation/ behavioral shaping Progression up hierarchy of feared cues vs. flooding Typically accompanied with relaxation/ breathing retraining
Types of exposures In vivo: Exposures carried out in real situations Imaginal: Exposures carried out in rehearsive imagination Interoceptive: Exposures carried out with focus on physical experiences Virtual Reality: Exposures carried out in computer simulated environments
Theoretical mechanisms Habituation: Natural reduction in fear response with repeated exposure Extinction: Overwriting previously learned fear associations Emotional processing: Developing new interpretations and meanings for feared stimuli and fearful responses Self-efficacy: Increased perception that one is capable of tolerating feared stimuli and responses Kaplan, & Tolin (2011)
Empirical support for diverse diagnoses PTSD Panic Disorder Phobias Social Anxiety Disorder/ Social Phobia Obsessive Compulsive Disorder Health Anxiety Substance Abuse/ Dependence Other anxiety-spectrum disorders
Examples of exposure therapy Prolonged Exposure (PE) for PTSD Cognitive Processing Therapy for PTSD (CPT) Eye Movement Desensitization Reprocessing (EMDR) for PTSD Barlow & Craske (2006) Panic Protocol Yadin, Foa, & Lichner (2012) OCD Protocol Hope, Heimberg, & Turk (2010) Social Anxiety Protocol
Exposure therapies with Veterans Strong national emphasis on evidence based treatment in VA/ DoD 2010 Clinical Practice Guidelines for PTSD VA/DoD Funding mechanisms oriented toward evidence based PTSD care
Exposure therapy in private practice Strong implementation of technology-facilitated care Medical Home Model Telehealth programming Home VTC Virtual Reality increasingly available Mobile applications Big data/ behavior therapy integration Trending towards exposure and technology
Technology in Exposure
Why augment usual exposure with technology Natural marriage to bring patient and clinician to environments better suited to exposure targets Evidence base for non-inferiority for: Telephone Videoconferencing Virtual Reality Emerging understanding of: Mobile monitoring mhealth/ mobile applications The email question
Exposure and technology Opportunity for technology to bridge gaps in practical barriers to exposure work. Consider: Limited time to plan and complete in vivo Limited resources to enact exposure (e.g., airplane tickets) When triggers are inherently dangerous (e.g., drug use, heights) When triggers are not accessible (e.g., combat environments)
Examples of use Seattle VA pioneers OCD treatment through in home videoconferencing group focused on exposure Mobile monitoring in homework tracking/ measure physiological responses to exposure Mobile devices to organize complex exposure protocols (e.g., PE Coach, PTSD Coach) or assist in skill building (Breathe 2 Relax)
Integrating Telephone and Mobile Devices in Care How Stuff Works
Telephone: Landline 60% of American homes have landline HIPAA privacy does not prohibit Security concerns differ Fewer concerns regarding user location Fewer interactions with recording/ transcription Not invulnerable to interception
Mobile devices US Mobile Access Mobile broadband access Smart Phone Mobile Device 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Mobile devices Increasingly used by general public Socialization, decision-making, information seeking online Independent of therapy, behavioral emphasis Weight loss applications Mindfulness applications Complement to therapy PTSD Coach PE Coach
Mobile devices
Mobile devices Different underlying technologies API s change constantly Unique risks: Privacy (volume, location, points of interception) Recording Analysis of data Online interactions, location MAL SSB 2014
Mobile devices Password protection Data storage (local vs. online) Carrier HIPAA permits NSA Snowden/ NYT Capabilities vs. what is being done
Exposure and the Telephone/ Mobile Devices
Therapy and the telephone
Telephone-based therapy Well-established method Typically augments exposure care May be stand alone care Historically used to check in between sessions, administrative
Exposure applications Therapist guided in vivo exposures (especially first exposures) Therapist guided skills training after session
Clinical recommendations Thoroughly establish protocol beforehand Establish safety plan Local resources Optional safety person Establish patient location at each call Consider interspersing with in-person or video
Technical recommendations Decide what type of telephony you will use Landline vs. Mobile vs. VoIP Communicate risks Shared or independent with personal use Recommend separate if you can use it If using VoIP Consider turning off transcription/ text alerts Consider whether you will answer unknown numbers If using mobile Consider where/ when you will answer device Password protect Do not share
Case Vignette: Telephone
Mr. Spock 55 year old divorced man Diagnosis of OCD Engaged in Distress Tolerance/ Response Prevention Challenges with operationalizing/ Triggers not available in outpatient setting (e.g., specific areas of home) Able to bring therapist to homework
Telephone intervention Set in vivo targets in prior session Set emergency plan in advance Determine where, when, how Purpose: review mechanics, cue for engagement, coaching
Successes and challenges Operationalized homework Phone call as avoidance? Boundary setting Reimbursement What are your concerns?
Exposure and Videoconferencing
Videoconferencing basics 25% of Americans have inadequate mental health care access (APA, 2009) Significant literature for best practices ATA Best Practices (2009), Evidence Based Practice (2009), Telepresenting (2011) SSB 2013
Videoconferencing
Applications in exposure Exposure therapy to clients with access limitations Innovative exposure in home or on site (e.g., hoarding) Guided skills training in home or on site (e.g., breathing retraining in crowded environment) Better opportunity to utilize natural exposure Better opportunity to engage in flooding protocols
Videoconferencing and rapport Technology disruption Eye contact/ body position Emotion/ animation Candor regarding moments when technology interferes SSB 2013
Videoconferencing: Patient environment Individual v. group Secure, private space Availability of Internet (better than dial-up) Web camera Computer/ mobile device Adequate memory/ processing speed (<5 years old)
Videoconferencing: Patient environment Consider where exposure occurs Consider whether you want a mobile device moving outside an area with an established safety plan Consider jurisdictional concerns
Videoconferencing: Provider environment Clinical space Lighting Background Adequate technical infrastructure More important for provider than patient Recommend redundancy when possible Technical support availability Where is the provider during exposure
Provider satisfaction
Videoconferencing and HIPAA considerations HIPAA compatibility Privacy rule, not security rule Marketing term Encryption Business Associate s Agreement Data treatment Reaction if breeched Some companies argue that if they are only a conduit Some companies listen in for security
Videoconferencing Publicly available vs. health care products Encryption Data infrastructure Different underlying technologies How does the data get from Point A to Point B Who can see it
Videoconferencing: Selecting a software Varying costs (free - $300/month; many $100/mo) Access vs. information security Informed choice Ease of patient use
Videoconferencing: Selecting a software Look for encryption Consider how data is transmitted Who can see the information Will company provide a Business Associates Agreement Do they listen in Do they provide transcripts, IM, recording
Videoconferencing: Selecting a software Technical support availability Ease of use For you The population you serve How will patients receive access Financial considerations Investment vs. risk
Videoconferencing software features Screen sharing Psychoeducation Exposures Homework review Split screens Multi-calls Privacy features Locked rooms/ password protection Ability to see who is in a room before you join SSB 2013
Unsung benefits
What not to do SSB 2013
CASE VIGNETTE: VIDEOCONFERENCING
Mrs. Uhura 31 year old married woman Sought treatment for depression and anxiety after birth Diagnosis of panic triggered by ambiguous cues interacting with son Not actively suicidal/ concern for harm to child Not able to bring child to hospital Lived in home with private space, hardware, Internet
Intervention Assess video appropriateness Technical Clinical Establish emergency plan Test installation/ tech use Delivered 21 sessions of treatment for depression and anxiety that included exposure to cues related to son (e.g., toys, allowing spouse to care for child, being away from child) Graduated to in-person care
Successes and challenges Engaged in care in a way that was accessible Ultimately, engagement in person care was challenging (some part attributable to anxiety) Messy Reimbursement Monitoring of child welfare (other cases) What are your concerns?
Delivering Care with Virtual Reality
Why VR Non-inferiority literature (not superiority) in exposure Benefits for time, cost Low engagement clients in exposure Safety Availability of triggers/ exposure stimuli
Integrating VR Access to large scale equipment through VA/ DoD Myriad vendors offer smaller scale solution USC, Skip Rizzo Barbara Rothbaum, Virtually Better DoD, National Center for Telehealth and Technology Phobioua, many others Vendors at national conferences Gaming driving this space (Oculus Rift, others)
How it works Typically akin to Prolonged Exposure (VRET) Client engages in breathing retraining, conducts trigger hierarchy In vivo exposure between sessions Start with imaginal, build to VR Some imaginal, but also VRET to access difficult to engage, reproduce Can bridge to imaginal exposure
How it works Diversity of stimuli Interactive visual environment Audio Many products have olfactory, tactile option
Case Vignette: VRET
What it looks like Many products in this space Demonstration of one available at Madigan Not endorsing one over another Live demonstration https://www.youtube.com/watch?v=gzddvq0zo4c
Mr. McCoy 20 year old Iraq Veteran Combat trauma, loss of friend Prior episode of care, underengaged Treated at joint military base/ VA VRET protocol with specific combat scenario recreated
Successes and challenges No VR environment is perfect Video game concerns Helped with underengagement Practical What are your concerns?
Integrating Home Monitoring in Care
Home monitoring Capturing patient data at a distance Biometric data (FitBit, cardiovascular care) Behavioral data (ADHD assessment, BA, medication compliance) Major growth area Integration to form new types of care Wearables Online monitoring/ interactive Difficult to speak about one category
Wearable monitoring
Intervention examples Heart rate monitor during imaginal exposure Tracking heart rate during in vivo exposure/ GSR Record ratings in PE Coach Use of Pedometer and other metrics in Behavioral Activation
Master Crusher 11 year old boy assessed for ADHD Dramatic inconsistencies in collateral reporting Use of HR monitor, pedometer and GPS to identify actual differential between reactivity at home and at school
Successes and challenges More accurate reporting/ less bias Patient engagement Can be fussy Costly Difficulty getting data in HIPAA appropriate way What are your concerns?
Home monitor take away Consider how/ if to integrate into practice Exposure therapy relies on habituation to stimuli/ direct monitoring Not exclusive to exposure work Consider application in assessment/intervention/homework Try using it yourself, if you haven t already
Common Threats to Security, Privacy and Confidentiality
Confidentiality vs. privacy vs. security Privacy: The condition or state of being free from public attention to intrusion into or interference with one s acts or decisions. Patient treatment is not public information Confidentiality: means the principle that data or information is not made available or disclosed to unauthorized persons or processes. Patient data is not released without their permission Security: Administrative, physical, and technical safeguards related to information software system How patient data is protected
Privacy
Security, privacy and confidentiality: Technology brings unique opportunities Difficult to speak to all technologies due to significant differences between them Providers are not engineers
Challenges Technology brings unique risks Confidentiality Breech: Smartphone bill received at home and viewed by spouse including phone numbers of clients Privacy Breech: Staff FB post with a location tag that she d seen notable client Security Breech: Virus on computer at work sent group email to all patients who approved email reminders for appointments all recipients could see all addressees
Caveat user
Security, privacy and confidentiality in exposure Where is the treatment room (e.g., office, car, store) Where is the patient s treatment room Where is your office? How planful are you for contingencies? How well do you understand the technology you use? How well do you understand where the client is/ who is near?
Best practices Determine what services you will provide via technology Consider stand alone vs. augment Interactive or static? In-person meeting when required and when possible (e.g., consent, identity) Which client populations, risk profile
Best practices Select a technology Meets your clinical needs Understand if data is encrypted Consider where the information goes/ is stored/ who access Who owns the data Consider investing in technologies designed for healthcare, use encryption, do not interact with data, breech history
Best practices Secure physical location and hardware Secure shared hardware and software Disposal plan Provide training to staff Use of professional equipment Interaction of private use of technology Plan for adverse events (e.g., virus, hacker, theft, damage)
Best practices Capture informed consent (written or online) Recruit clients as advocates for own privacy Use technology properly Secure wi fi, when appropriate Use dedicated, password protected profiles and accounts for interactions with providers No forwarding, recording, etc.
Guidelines and Regulations
Laws & regulation Minimum requirements for practice Technology emerging integration into law Most psychologists are NOT lawyers Be mindful that jurisdictions DIFFER Consult best practice guidelines Consider your employment setting policies and procedures Consider that federal laws may apply (i.e., HIPAA, HITECH)
Regulatory considerations Are there jurisdiction requirements (local, state, federal, international) related to technology and practice of psychology? Where does care occur? Is there reimbursement issues related to technology use in practice of psychology (i.e., billing of testing) MAL SSB 2014
What is interjurisdictional practice? Providing care outside your licensure jurisdiction via technology Can occur when either the provider is in a non-licensed jurisdiction, or When the client is in a jurisdiction that the provider is not licensed in and receiving services Salient but not exclusive to telehealth
Interjurisdictional requirements Currently there is no federal licensing law ASPPB PSYPACT
IJP
Ethical Guidance
Ethics Less ethical and empirical guidance for technology enabled exposure VR literature dates to 1990s If exposure is a gold standard, then tech is alchemical Guidelines documents provide assistance APA, ATA, forthcoming WSPA Collegial consultation (professional judgment) Document who, when, content
Ethics
Emergency management
Emergencies
Emergencies Often heightened concern in exposure Clients receiving interactive remote care have emergency plan Consider what you will do in case of medical or psychiatric emergency (e.g., local hospital, wellness check, others). Problems that do not meet mandated reporting threshold but cause concern Availability of support person
Best practices Determine level of client and clinical stability you are comfortable with Screen clients accordingly Use with existing clients Screen clients for technical knowledge/ availability of appropriate endpoint (e.g., quiet, private) Consider what services you are comfortable providing over what modalities In vivo over video vs. response prevention over phone
Best practices Create unique emergency plan for each exposure technology patient Consult with others doing similar work Look around you! ATA SIG VA TMH Institute Develop templates, esp. informed consent Document this plan within the client record, keep available for review
Educating clients and informed consent
Consent at home SSB 2013
Introducing clients to technology Education as predictor of technology success Education regarding exposure part of most manuals What is your ability (time, competence) to train clients Impact on client selection for technical experience Consider creating a 1-page document reviewing: How this augments standard exposure therapy How to use Appropriate use Troubleshooting/ technical resources MAL SSB 2014
Informed consent for new service Apprises clients of the risks and benefits Provides education to the client of service boundaries and limits Use clear language for variety of levels of technical sophistication SSB 2013
Informed consent for new service Be prepared to discuss exposure and technology facilitating it Be explicit regarding your technology experience (or inexperience) Be prepared to answer questions/ find answers Capture documented informed consent
Informed consent
Educating clients of risks Apprising clients of risks (esp, privacy, confidentiality) Use of technology introduces risk/ what steps taken to mitigate risks Whether/ how information is recorded and stored This information can be subpoenaed Who can access stored information Impact on emergency management SSB 2013
Educating clients of service benefits Unique exposure opportunities Access Geographic, medical issues, financial concerns, convenience Specialty otherwise unavailable Dual role (esp., in rural communities) Convenience (e.g., cost, asynchronous) SSB 2013
Educating clients of service limits Usual limits of confidentiality apply Consider any unique to the modality (e.g., email, text) Confidentiality limited by security of technology (e.g., system problems, authorized access by administrators, potential discovery by other users) Limits of what you address clinically over modality and your response How you will respond to inappropriate technology use SSB 2013
Educating clients of service limits Address whether this is stand-alone service or augment Especially relevant for in office visits augmented with at home exposure Crisis management capacity and plan Availability for response/ time frame Client responsibilities Role in security (e.g., forwarding, recording) Client technical requirements SSB 2013
Educating clients of service limits What to do in case of technology failures Clinically (imaginal?) Practically Conflicts in jurisdictional rules/ how it will be handled Capturing documented informed consent SSB 2013
Educating clients of service limits Billing information Service fee Technology fees How billing will be handled if service disrupted How information security breach with be managed How service termination will be managed SSB 2013
Enlist clients as advocates for security Password protect computer, mobile device used for exposure Secure WiFi Do not record without consent Abide by agreed upon strictures, alternate options Being alone in remote treatment room Ask questions
Integrating technology enabled exposure into your practice
Determining which therapies Which exposure-based therapies? PE, VRET, OCD protocol, Panic protocol Which modalities? Telephone? Video? VRET? Mobile Apps Others?
Which clients Popular factors to consider (esp. for remote service): Care engagement Care access (e.g., distance, medical, financial) Patient preference Clinical issues (e.g., diagnosis, avoidance, substance abuse, treatment history) Clinical stability (i.e., likely emergency) Ability to meet in-person Client care environment (e.g., office, home) Insurance/ reimbursement Privacy/ stigma
Social exposure
Which clients Technical ability of client Your ability to teach client Age, gender, education or technology experience are not as important as a good explanation Does the client possess technical resources Computing device Adequate internet speed Hardware/software Mobile device, phone
Not the perfect client
Handling emergencies Clients receiving interactive remote care have emergency plan May be more lenient when augmenting in person care (VRET) Consider what you will do in case of medical or psychiatric emergency (e.g., local hospital, wellness check, others) Problems that do not meet mandated reporting threshold but cause concern Availability of support person
Best practices Determine level of client and clinical stability you are comfortable with for exposure and technology Screen clients accordingly Draft policies (informed consent, emergency templates) Screen clients for technical knowledge/ availability of appropriate endpoint (e.g., quiet, private) Consider what services you are comfortable providing over what modalities PE over videoconferencing; augment CPT with phone
New social phobia treatment
Selecting your technology Look for products made for healthcare Mobile phone encryption Videoconferencing for healthcare Mobile Apps by reputable vendors (Universities, DoD, others) Obtain a BAA when appropriate/ possible Consult with your legal counsel Malpractice attornies Document your decisions
Questions and Answers
ssmucker@post.harvard.edu 253-642-7113 Thank you!