Academic Psychiatry continues to further the role of technology in clinical care and education in several ways. The articles on evidence-based approaches to tele- and e-behavioral health in this issue remind us of several core medical, psychiatric, pedagogic, and technical tenets. Academic health centers promote the current and next-generation’s education through innovative approaches to research, clinical care, and faculty development. Innovations in medicine and technology (e.g., telepsychiatry) invite clinicians to practice and advocate for underserved populations without access to quality care due to geographical, cultural, and other barriers) [1]. Telepsychiatry also empowers patients, personalizes care, and increases administrative efficiency and communication. A new range of technologies challenges clinicians, trainees, and educators to ensure high-quality clinical care, professional standards, and sensitivity to differences in participants [2].

The articles in this issue are geared to help trainees, clinicians, faculty educators, and others improve care via clinical and technological competence. In order to do that, the profession has to consider new applications of technology as instrumental, rather than supplemental, to practice and teaching (e.g., “instructional technology”). The articles provide a broad perspective on what clinicians, trainees, patients, and the public are doing with technology and how they are using it in clinical care, education, and everyday life. A range of technologies is discussed, including social media [3] and smartphone apps [4]; these have been used across mobile health and other platforms [5].

Articles in this issue delve into telecompetencies, which are becoming an essential part of the clinical toolkit skills and practices. Indeed, telecompetencies help align targeted clinical outcomes with teaching/supervisory methods, evaluation, and feedback. One paper provides an overview of why we need not just telepsychiatric competencies but also telebehavioral health competencies across mental health specialties [6]. Another paper spells out the domains: clinical evaluation and care; administration; cultural competence and diversity; legal and regulatory issues; evidence-based and ethical practice; and mobile health, smartphone, and apps [7]. Telepsychiatric competencies are updated [6], and specific competencies for social media are offered [3].

Several articles offer fresh ideas on how to use technology for teaching faculty, course and clerkship directors, program directors, and other leaders to advance medical and psychiatric residency education [8,9,10]. There are options for those interested in incorporating technology into the psychiatric residency curriculum [9] or developing a digitally informed curriculum in psychiatric education and practice [10]. Crawford et al. [11] offer three educational reports across the learning continuum to describe how to build ehealth and telepsychiatry capabilities, including those geared toward underserved, primary care, and integrated care populations. Ratzliff et al. [12] also look at tele-behavioral health in collaborative and integrated care. Finally, an article thinks through the professionalism implications for practice and education [13].

Competencies are a focus of undergraduate and graduate medical education but have yet to be fully described in the continuing medical education (CME) realm. The educational outcomes of the American Association of Medical Colleges (AAMC) are evidence-based, including the domains of medical knowledge, patient care skills and attitudes, interpersonal and communication skills and attitudes, ethical judgment, professionalism, lifelong learning and experience-based improvement, and community and systems-based practice [14]. The Accreditation Council for Graduate Medical Education (ACGME) specifies patient caremedical knowledge practice-based learning and improvement, systems-based practice, professionalism, and interpersonal skills, and communication domains [15]. The AAMC framework on pre-entrustable and entrustable professional activities for entering residency [16] attempts to bridge gaps between knowledge and skills/behaviors. CME still lacks an integrated plan of competencies, despite consensus- and evidence-based guidelines and accreditation, legal, and regulatory agency policies.

The collection of articles in this issue is founded on other critical considerations. First, clinical care is only as good as the outcomes that are prioritized and evaluated. The Institute of Medicine and its Health Professions Education Summit [17, 18] linked health care professional training with quality of care, safety, and interdisciplinary skill objectives for patient-centered care, interdisciplinary teams, evidence-based practice, and information technology (IT). Another consideration is that lifelong learning is an ongoing necessary process for all psychiatrists—as supported by the American Board of Psychiatry and Neurology (ABPN) and the American Psychiatric Association, based on a lifelong learning platform [19].

Technology, now ubiquitous in everyday life, has had no “home” in mental or behavioral health or psychiatric journals. The collection of articles in this issue builds on a previous issue of Academic Psychiatry in 2006 on the use of technology for education and on the innovations and technology in education column. The Telemedicine Journal and E-Health, Journal of the American Medical Informatics Association, and Journal of Medical Informatics Research—Mental Health have some focus on these topics, but unlike Academic Psychiatry, education is not the focus. The new Journal of Technology in Behavioral Science focuses on telecompetencies across professions.

Trends in Clinical Care, Use of Technologies, and Competencies

This collection of articles takes a look at technologies applied to clinical and educational activities, as well as everyday life. It moves beyond telepsychiatry, a common service delivery option for over 20 years with a strong evidence base, to a mental or behavioral health-related continuum of technology-based options for patients, families, caregivers, and professionals. The field is exploring the interface between these technologies (e.g., a system) and the participants (e.g., individual/group, patients, virtual characters) [2]. This continuum includes Internet-based information; self-help/support groups; well-prepared materials for patient and clinician education; use of social media; self- and clinician-assisted assessment; asynchronous text, e-mail, and video; mobile health with apps; and synchronous video (Table 1) [2].

Table 1 A tele-behavioral health spectrum of technology use in health and clinical care: issues for patients and clinicians
Full size table

Being aware of how patients and populations at large are using technology is important [1, 20, 21]. Patients may at times prefer low intensity options for services (e.g., patient education modules, text/e-mail interventions) that, if researched and effective, may nicely complement traditional in-person and telepsychiatric care options. Indeed, technology is a “practice extender” by performing some of the tasks that clinicians and staff have done to integrate care [22]. Perhaps more broadly, it can be considered an integral “team member” of a stepped care approach. It is hoped that these technologies will be better included in the electronic health record and/or part of a broader, mobile health platform.

The telepsychiatric competencies in 2015 [23]—the first telecompetencies published—were based on the ACGME [15] and CanMEDS [24] frameworks, in six domains: patient care, communications, system-based practice, professionalism, practice-based improvement, and knowledge. These competencies adapted the Dreyfus model for learners (5 levels: Novice, Advanced, Competent, Proficient, and Expert) [25] but combined them into Novice/Advanced Beginner, Competent/Proficient, and Expert levels. The Coalition for Technology in Behavioral Science developed an interprofessional, evidence-based framework for measurable telebehavioral health competencies [6, 7, 26, 27] in seven topic domains: (1) clinical evaluation and care, (2) virtual environment and telepresence, (3) technology, (4) legal and regulatory issues, (5) evidence-based and ethical practice, (6) mobile health and apps, and (7) telepractice development.

Social media and networking competencies in the graduate medical education domain framework were recently posited [7, 28] and are advanced in this issue [3]. Along with mobile health, smartphone/device, and app competencies, these technologies pose substantial challenges (e.g., asynchronous, not structured like traditional care visits, affect the therapeutic frame, create additional boundary issues). Advantages of these technologies include portability, accessibility across time and place, affordability, and the potential for additional features.

Clinical Issues and Challenges

Ethics, professionalism, and the law are domains with substantial overlap. Psychiatrists are typically held to a higher ethical standard than other physicians because of the nature of their work. Publicized breaches of professionalism online spurred the development of a field now called “digital ethics” or “e-professionalism” due to reports by deans and state medical boards [29, 30] and the media. Current use and misuse of technology by residents and medical students is difficult to assess.

Delivering mental health care through technology has many potential clinical, legal, professional, and communication ramifications [13]. Clinicians should screen patients about their use of technology, evaluate its impact, and be mindful of informed consent documentation and licensing and other legal requirements when using technology with patients [27]. The American Psychological Association Guideline for the Practice of Telepsychology [31] includes many components: clinical (e.g., informed consent, documentation, confidentiality, adjusting assessments), ethical, educational, legal and regulatory, and security and management of data.

Other key themes across traditional video, Internet, mobile device, and other technologies include quality of information; how to communicate via texting, e-mail, and apps; therapeutic and boundary issues; and practitioner and patient privacy. While not wholly new, these issues raise unexpected and unintended consequences and challenges like verification of identity/authenticity, data “permanence” of information posted, public sharing of personal versus professional information, and searches conducted by the public, patients, and clinicians. Clinicians are expected to safeguard patients’ privacy and inform them of potential risks and benefits in the use of technology in the clinical setting.

Administrative, Business, and Reimbursement/Financing Issues

For administrators, attending to technology-related issues is another challenge. Telepsychiatry provides versatility to health care systems by enabling more patient points-of-entry, matching patient needs with provider skills, and helping providers work at the top of their licenses. Telepsychiatry and other technologies make collaborative, stepped, and integrated care less costly and more accessible. Effective health care delivery matches the intensity of the services to the needs of a patient population or clinic, standardizes interventions, and evaluates both process and clinical outcomes.

Theoretically and practically, evaluation of clinical skills/behaviors should dovetail with evaluation of clinical care. Perhaps a finite, but manageable, subset of faculty and trainees’ behaviors could be efficiently evaluated with regard to core concepts related to quality care and decision-making. If clinical supervisors and program directors work with administrators, the learning and clinical objectives can be aligned with the instructional method [32, 33] and policies and procedures for technology (e.g., electronic documentation). More than ever, teamwork is needed across professions and disciplines, teaching and clinical faculty, evaluators and students/clinicians, managers, and staff. Research findings must be translated into models of teaching, practice, and assessment.

Another challenge is in consolidating information in an effort to enhance decision-making, whether at the level of a clinician and/or a psychiatric leader. The amount of information is skyrocketing, and it is not integrated across public, private, and health system datasets and systems. Electronic health records are standard, but systems do not smoothly interface between systems and clinicians. This lack of ability to interface across systems restricts automated capture, processing, and utilization, which decrease the return on investment for technology. And perhaps worse, each new innovation is costly and often fails to provide a platform on which new data can be smoothly flow and be integrated.

In the growing flood of data, medicine is caught largely reacting instead of getting ahead of the problem. In business, shared domain knowledge and common understanding between the IT and the line managers has improved performance [34]—if it is done with a specific goal in mind and as part of a strategic approach. Competition in business made this a “life and death” proposition for survival rather than elective, but the result was a competitive advantage by abandoning manual processes in systems, even if there was disruption [34,35,36,37]. A strategic approach using this shared IT-business—or shared IT-psychiatric or IT-medical understanding—could (1) reduce supplemental, technological add-ons to the organization; (2) reduce expenditures; (3) increase reliance on integrative rather than manual (or siloed computer) systems for communication, evaluation, and queries; and (4) enhance long-term planning.

Technology could be central to health care transformation and improvement. Currently, Americans pick technology and obtain health care like a commodity—searching for the best service, price, and time—even though health care is viewed as a right and is best distributed by a central, equitable process [38, 39]. One might imagine a more systematic approach in which technology was harnessed to key goals of patient-centered care and value-based care as part of an overarching system coordinated by the Centers for Medicare and Medicaid Service. Such an approach might better tie reimbursements to clinical care, quality, patient experience, safety, efficiency, and mortality [40, 41] and potentially slow the growth of health care expenses [42], as has been demonstrated well in the Canadian and Japanese health care systems [43,44,45].

Academic psychiatrists and other mental health clinicians influence the future of the profession at the level of both the individual (e.g., trainees) and local and national systems. Technology is permeating future education and training, clinical practice, and research. This collection offers expert thinking about current practices and future needs across a wide variety of domains and settings with the goal of improving access to and quality of care across populations nationwide. There are many implications of telepractice for departments, schools, academic health centers, psychiatric workforce, and international organizations. There is much to learn about implementation and evaluation of competencies, change management, and prioritization of technology by leaders.